
Class 
Book 



COPYRIGHT DEPOSIT 



CONSTIPATION 

IN ADULTS AND CHILDREN 




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(From Luschka, " Die Lage der Bauchorgane," etc.) 



Frontispiece. 



19, Right lobe of the liver; 20, Quadrate lobe; 21, Left lobe of the liver; 22, The 
suspensory (broad) ligament of the liver, cut off; 22*, Fundus of the gall-bladder; 
23, Oesophageal (upper) orifice of the stomach ; 24, Cul-de-sac of the stomach, partly- 
overlaid by the left lung; 25, Pyloric end of the stomach; 26, Section of the stomach 
which lies in the epigastrium, and is partly covered by the liver ; 26*, Arteria gastro- 
epiploica dextra, corresponding to the course of the greater curvature of the stomach ; 
27, Caecum ; 28, Appendix Vermiformis ; 29, Ascending colon ; 30, Right colic flexure ; 
31, Transverse colon; 32, Left colic flexure; 33, Descending colon; 34, Dotted lines, 
showing position of sigmoid flexure underneath the small intestines ; 35, Small intes- 
tines in the arrangement most commonly found; 36, Obliquely ascending end of 
small intestines ; 37, Summit (apex) of bladder covered by peritoneum ; 38, Anterior 
and lower portion of bladder (in a state of moderate distention and reaching beyond 
upper border of pelvis) free from peritoneum. 



•Th^^o 












Microscopic Appearance of some Constipated Faeces 
tA Case of Four Year's Duration 



CONSTIPATION 



IN ADULTS AND CHILDREN 

WITH SPECIAL REFERENCE TO 

HABITUAL CONSTIPATION AND ITS MOST 

SUCCESSFUL TREATMENT BY THE 

MECHANICAL METHODS 



BY 

H. ILLOWAY, M.D. 

FORMERLY PROFESSOR OF THE DISEASES OF CHILDREN, CINCINNATI COLLEGE 

OF MEDICINE AND SURGERY ; FORMERLY VISITING PHYSICIAN TO 

THE JEWISH HOSPITAL, CINCINNATI; ETC., ETC. 

MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK 

OF THE NEW YORK COUNTY MEDICAL ASSOCIATION, ETC. 




THE MACMILLAN COMPANY 

LONDON: MACMILLAN & CO., Ltd. 

1897 

All rights reserved 



«$> 



' ->> 



\ 



Copyright, 1897, 
By THE MACMILLAN COMPANY. 



NottoooB 33ress 

J. S. Cushing & Co. - Berwick & Smith 
Norwood Mass. U.S.A. 



TABLE OF CONTENTS 
Part I 

SECTION I 
CHAPTER I 



TO PAGE 



Anatomy of the Intestines. (With reference mainly to the large 
bowel; its position in the abdominal cavity; the internal arrange- 
ment of its mucous membrane.) The vessels. The nerves — show- 
ing the relation of the bowels to the cerebral and the spinal centres 27 

CHAPTER II 
Flatus ' ■. . , 30 

CHAPTER III 
Intestinal Peristalsis. Defecation ....... 39 

CHAPTER IV 

Fjeces (appearance thereof under the microscope) . . . .42 

CHAPTER V 
Definition; Etiology; Classification 46 

CHAPTER VI 

Acute Constipation ; Etiology. (En parenthese, an account of for- 
eign bodies that may cause such, with histories of cases to illustrate 
the mode of treatment when sharp bodies, as knives, etc., have 
been introduced) 56 

CHAPTER VII 

Chronic Constipation; Etiology. The various maladies that may 
give rise thereto — Foreign bodies (with histories of cases) — Mal- 
formations of the intestines — Dislocation of the intestine — Essen- 
tial primary atrophy of the intestine 87 

vii 



Vlll TABLE OF CONTENTS 



CHAPTER VIII 

TO PAGE 

Spastic Constipation. Enterospasm — Enterospasm and atony — 
Spasmodic stricture of the rectum — Spasmodic contraction of the 
sphincter of the anus without fissure — Irritable sphincter . . 94 

CHAPTER IX 
Atony of the Intestine. Causes — Mode of action . . . 105 

CHAPTER X 

Symptomatology. General and local symptoms . . . .112 

CHAPTER XI 

Diagnosis. Methods of examination ; percussion, palpation, inflation 

— Faeces, microscopic examination of. 

Prognosis 132 

CHAPTER XII 

The Consequences of Constipation. Haemorrhoids — Anal Fis- 
sure — Typhlitis — Appendicitis — Enteritis membranacea — Proc- 
titis — Faecal tumors — Dislocation of the bowel — Ulceration of 
the bowel — Ulceration with hypertrophy — Diverticula . . 166 

CHAPTER XIII 

The Consequences of Constipation, Cont. Diarrhoea with consti- 
pation — Ileus — Jaundice — Torpid liver — Atony of the stomach 

— Auto-intoxication . . - 176 

CHAPTER XIV 

The Consequences of Constipation, Cont. Disturbances of the 

nervous system — Pyschoses — * * * — Chlorosis . . . 185 

SECTION II— TREATMENT 

CHAPTER XV 

Treatment of Constipation due to Atony of the Intestine. 
Hygienic rules — Dietary regulations ; diet list — Exercise ; rules 
for same 203 

CHAPTER XVI 

Treatment of Constipation due to Atony, Cont. Massage ; gen- 
eral technic of — Special manipulations — Schedules of manipu- 
lations — Duration of treatment — Instrumental massage . . 243 



■MM 



TABLE OF CONTENTS IX 



CHAPTER XVII 

TO PAGE 

Treatment of Constipation due to Atony, Cont. Swedish move- 
ments — Machine gymnastics — Contra-indication to massage . 264 

CHAPTER XVIII 

Hydrotherapy. Special procedures — Schedule of temperatures for 

water 2S3 

CHAPTER XIX 

Electricity. Modes of application ....... 299 

CHAPTER XX 

Medicines. Nux vomica (Strychnia) — Calabar bean (Physostigma) 

— Ergot — Zinc — Ammonii chloridum 305 

CHAPTER XXI 

Effects of Treatment; Complication . 308 

CHAPTER XXII 

Treatment of Conditions related to Atony. Ileus — Paraly- 
sis of the intestine — Atony of the rectum 317 

CHAPTER XXIII 

Treatment of Atony of the Intestine dependent upon Morbid 
Processes. I. Constipation dependent upon intestinal catarrh — 
II. Atony from morbid processes elsewhere: 1. Neurasthenia ; 
2. Debility after protracted maladies ; 3. Disease of the heart . 324 

CHAPTER XXIV 

Treatment of Spastic Constipation . . . . . . 333 

CHAPTER XXV 

Treatment of Constipation due to Irritable Rectum . . 340 

CHAPTER XXVI 

Treatment of Constipation dependent upon Genito-urinary 

Troubles 343 

CHAPTER XXVII 
Fissure of the Anus 345 



X TABLE OF CONTENTS 



CHAPTER XXVIII 

TO PAGE 

Hemorrhoids. Relief of the constipation due to them — Non-surgi- 
cal treatment of 353 



CHAPTER XXIX 
Oil Injections. Technic of „ 359 

CHAPTER XXX 

Other Methods of Treating Constipation (recommended by 
various writers). 1. Stretching of the sphincter ani ; 2. Applica- 
tion of boracic acid to the anus ; 3. Treatment by river-gravel 
(Flusskiesel) ; 4. By suggestion 365 

CHAPTER XXXI 
Treatment of Constipation in Old People 369 

CHAPTER XXXII 
Formulary 383 

Part II 

CONSTIPATION IN INFANTS AND CHILDREN 

CHAPTER I 

Introduction ; Classification. 

Congenital Constipation. Malformation of the rectum and anus 

— Of the colon — Of the small intestines — Malplacement . . 412 

CHAPTER II 

Acquired Constipation. 

Acute Constipation, Etiology 418 

CHAPTER III 
Chronic Constipaton, Etiology 422 

CHAPTER IV 
Habitual Constipation, Etiology . 428 



TABLE OF CONTENTS XI 

CHAPTER V 

TO PAGE 

Habitual Constipation due to Atony, Cont. .'"... 434 

CHAPTER VI 

Habitual Constipation due to Atony, Cont. Habitual constipa- 
tion in older children 437 

CHAPTER VII 
Symptoms and Diagnosis ......... 440 

CHAPTER VIII 

Treatment of Constipation due to Atony of the Intestine 
(Infants). General measures — Special measures (remedies, injec- 
tions) — Massage — Secondary measures 455 

CHAPTER IX 

Treatment of Constipation due to Atony of the Intestine, 

Cont. Older children .,-.'. 458 

CHAPTER X 

Some Anatomical Considerations .;...„.. 464 

CHAPTER XI 
Massage. Preliminary considerations .....•.'. 469 

CHAPTER XII 
Massage. Technic of manipulations for infants and young children 480 

CHAPTER XIII 

Spastic Constipation. 

Fissure of the Anus 484 

CHAPTER XIV 
Formulary ......... 488 



LIST OF ILLUSTRATIONS 



Part I 



Frontispiece, showing the abdominal organs in position. 

The duodenum and surrounding structures 4 

The caecum, showing funnel-shaped terminal extremity of the ileum, 

and the appendix vermiformis 7 

The large bowel in position 8 

The caecum laid open, showing orifice of appendix vermiformis . . 10 

The sigmoid flexure 12 

The sigmoid flexure . 4 13 

The external sphincter of the anus, perineal muscles in man . , .15 

Sacculi Horneri 18 

Diagram of the nerves of the intestinal tract 21 

The plexus of Auerbach 23 

The plexus of Meissner 24 

The male perineum, showing distribution of nerves .... 25 

Normal faeces 41 

Human colon, congenital giant growth .67 

Diverticulum, congenital, of the sigmoid flexure 77 

Illustration of enteroptosis .80 

Upward dislocation of transverse colon 81 

Dislocation of the sigmoid flexure to the right . . . 85 

Abdomen, where to examine 119 

Arrangement of apparatus for inflating the bowel with gas . . .122 
Arrangement of apparatus for inflating the bowel with air . . .123 

Crystals of haematoidin 127 

Teichmann's haemin crystals Il'7 

Colored Plate, showing microscopic appearance of some constipated 

faeces, between pages 128 and 129 

Demi-schematic view of the external surface of the ampulla of the 

rectum 133 

xiii 



XIV 



LIST OF ILLUSTRATIONS 



Demi-schematic view of the internal surface of the ampulla of the 

rectum 

False diverticula, of the large bowel 
Distention diverticula, of the small intestine 
Diverticulum of the ileum 
Bandages for the abdomen 

Abdominal bandage 

Effleurage with the tips of the fingers 

Frictions with the thumb 

Petrissage with the thumb .... 

Petrissage with the thumb and finger 

Diagrammatic illustration of position of patient for massage 

Division of the belly with one hand . 

Division of the belly with two hands 

Polling of the belly with one hand . 

Rolling of the belly with two hands . 

Petrissage of the abdominal walls 

The Kammgrifi* 

Kneading of the belly ..... 

Punctation 

Circular effleurage 

Position of hands for operator . 

To break up indurated faeces in caecum and ascending colon 
To break up indurated faeces in transverse colon 
Manipulation for ascending colon, liver, and gall bladder 
Transfer movement, for caecum and ascending colon 
Transfer movement, for transverse colon .... 
Transfer movement, for descending colon and sigmoid flexure 
Position of hands for petrissage, of sections of colon 
Position of hands for petrissage, of sections of colon 



Kneading and raising of sigmoic 
Vibration of solar plexus . 
Hacking of the belly . 
Clapping of the belly . 
Tapotement a Pair comprime 
Beating of the sacrum 
Kahn's roller 
Figs. 1-10, Active movements 



flexure 



241 



134^ 

163 

1G4 J 

165^ 
20b 
202 - 
207- 
.207 
208 
209 
212 
214 
215 
216 
216 
217 
218 
219 
219 
220 

221 J 

222 • 
223- 
225 
227^ 

228 - 

229 ' 

230 j 
230 i 
231, 
232 
233 
234 
235 
236 
242 

-249 



LIST OF ILLUSTRATIONS 



XV 



PAGE 

Figs. 11-18, Movements against resistance 250-255 

Figs. 19-23, Passive movements 257-258 

Fig. 24, Row boat of Sachs .261 

Fig. 25, Row boat of Ewer . . .261 

Fig. 26 a, Movements with Sachs restaurateur 261 

Fig. 26 b, Goodyear's pocket gymnasium 261 

Outline of enlarged spleen 262 

Self-acting clysopump 265 

Force pump . . . . 267 

Application of the wet sheet .274 

Sprinklers 279 

Rectal electrodes 289 

Bipolar rectal electrodes 289 

Atzperger apparatus . 337 

Winternitz's device 338 

Bottle for generating carbonic acid 339 

Psychrophor 341 

Hsemorrhoidal bandage 349 

Tip for syringe (for oil injection) 355 

Rectal bougies 361 

Whitehead's instrument . . . . . . . . . .361 



Part II 



Frontispiece I. Abdomen of infant twelve days old laid open, small 

intestines in sitn. 
Frontispiece II. Same, showing large bowel, liver, and stomach. 
Congenital contraction of the ascending and transverse colon, etc. 
Congenital obliteration of the small intestines , 
Ileum with diaphragms . . 
The abdominal viscera of a new-born infant held i 
Diagram of the above ..... 

Diagram showing direction of manipulation 
Manipulation II. for infants 
Diagram showing direction of manipulation 
Manipulation III. for infants 
Manipulation IX., thumb movement . 



erse colon 


, etc. 




395 




401 








407 


position 






462 
463 
471 
471 
472 
473 
476 



PART I 

CONSTIPATION IN ADULTS 



CONSTIPATION IN ADULTS 



>XKc 



SECTION I 

CHAPTER I 

ANATOMY OF THE INTESTINES 

The part of the human body that principally concerns 
us here is the intestinal canal, consisting of two distinct 
and characteristic parts, — the small intestines and the 
large bowel. 

The small intestines constitute by far the major part 
of the intestinal tract. The average length in the adult 
male (between the ages of twenty and fifty) is twenty-two 
feet, six inches ; in the female it is twenty-two feet, four 
inches. Exceptionally it is found, both in the male and 
female, longer or shorter by some feet. 

The intestinal tract proper begins at the stomach, 
from which it is separated by the sulcus pyloricus, with 
that portion known as the duodenum. Ever since the 
days of Herophilus the small intestines have been divided 
into three parts, — the duodenum (twelve fingers, eight to 
ten inches), the jejunum, and the ileum. There is, how- 
ever, no line of demarcation that separates the duodenum 
from the jejunum, or any distinctive feature by which to 

3 



4 CONSTIPATION IN ADULTS 

recognize the one from the other. Luschka has therefore 
proposed that the duodenum and jejunum be grouped 
together as one part and be called the pancreatico-bilious 
intestine (intestinum pancreatico-biliosum). 

The duodenum takes its origin at the pyloric extremity 
of the stomach, on the right side of the epigastrium, 
about the level of the last dorsal vertebra, and ends on 




The Duodenum and surrounding Structures. (Sappey.) 

1, Pars horizontalis superior, thrown back to the right; 2, Pars descendens or 
verticalis ; 3, Pars horizontalis inferior. 

the left of the spinal column, about the level of the third 
lumbar vertebra, in the jejunum. Between the points 
here described it changes its course three times and is 
therefore divided into three segments, — some have it 
four, — the jiars horizontalis superior, the pars descendens 
or verticalis, and the pars horizontalis inferior. The 
fourth part described by some is the pars ascendens. 



ANATOMY OF THE INTESTINES 5 

The pars horizontalis superior. Beginning at the 
stomach, as already described, it runs outward and some- 
what upward to the right in a horizontal direction, with 
a tendency to obliqueness. The position varies, of course, 
considerably with the movements of the stomach, becom- 
ing more transverse when the longitudinal fibres of that 
organ are contracted, and more oblique when the stomach 
is dilated. The position undergoes change in gastrop- 
tosis, whether this be partial, as when the pyloric portion 
alone is dislocated, or complete. This portion of the duo- 
denum is the widest of this section of the small intestine 
and is about two or three inches in length. It is some- 
what bottle-shaped, dilated more at its upper extremity 
to form the antrum duodenale. It is covered by the 
lobus quadratus and the right lobe of the liver. This 
segment is freely movable and is almost completely 
invested by the peritoneum. The pars verticalis (de- 
scending segment) runs down in front of the right kidney 
as far as the third lumbar vertebra. It does not descend 
in a straight line, but makes a gentle curve and merges 
almost imperceptibly into the inferior transverse portion. 
Joined to this latter part it gives to the duodenum the 
configuration of a horseshoe with the convexity looking 
to the right and the concavity to the left. In the con- 
cavity is received the head of the pancreas. On the 
inner surface of the vertical segment just below its middle 
is the orifice of the ductus communis choledochus, and 
just a little above this the separate orifice for the duct of 
the pancreas. It is covered by peritoneum on its anterior 
surface only. The pars horizontalis inferior, the longest 
and narrowest part of the duodenum, passes over trans- 



6 CONSTIPATION IN ADULTS 

versely from the right side to the left and at the left 
border of the spinal column ends in the jejunum. That 
which by some is described as a fourth change in direc- 
tion, or fourth segment, is the ascent made by the 
terminal extremity of the duodenum from the third to 
the second lumbar vertebra, at which point the jejunum 
may be said to begin. It has a partial investment of 
peritoneum on its anterior surface. It is covered in front 
by the transverse mesocolon and crossed by the superior 
mesenteric vessels ; it lies upon the aorta, vena cava, and 
the crura of the diaphragm. Above it is the lower 
border of the pancreas. 

Jejunum and Ileum. — The jejunum is two-fifths of the 
residue of the small intestine. It begins at the point 
already described, descends, makes numerous convolu- 
tions, and merges into the ileum. The ileum is the 
residue of the small intestine, and is the narrowest 
portion of it. The gyri or ansae, which these two 
segments form, are very numerous, and they lie closely 
packed together. They are arranged in a very irregular 
form, from left to right. Leaving the duodenum, they 
fill the contiguous left epigastric and umbilical regions, 
then the left hypochondriac and left lumbar regions, 
descend into the pelvis, reascend into the left iliac, 
pass over the hypogastric into the lower umbilical, right 
hypochondriac, and right lumbar regions. The ileum 
terminates here in that portion of the large bowel known 
as the caecum. This terminal extremity is rather funnel- 
shaped, the wide portion of the funnel directed toward 
the ileum. 

By means of the mesentery, which is a fold from the 



ANATOMY OF THE INTESTINES 




peritoneum, and which with its two layers, the ascending 
and descending, forms the peritoneal covering of these 
two segments of the 
small intestine, they are 
hung up, as it were, on 
the spinal column. 

The capacity of the 
small intestine is equal 
to six litres (about twelve 
pints). 

The Large Bowel. — 
The large bowel, intes- 
tinum crassum sen am- 
plum, is about five feet 
in length, with occa-' 
sional variations as in c 

Showing C^cum and Funnel-shaped Ter- 
the Case of the Small minal Extremity of the Ileum. (Sappey.) 

intestine. It begins at *> Line of division of the small intestine; 

. 2, Opening of the small intestine into the large 

the termination of the bowel ; 3, Lower section of ileo-caecal valve ; 

• -. -. -j , 4, Upper section of ileo-caecal valve ; 5, Bundles 

Ileum ana. enQS at tne f muscle-fibre passing over from the small on 

anUS. It is latest at Jo the large bowel ;6, Lower section of c*cum ; 

i* <_,v^u i*u ^ Appendix vermiformis; 8, Posterior outer 

the C86CUm and STadu- t8en ^ a > 9, Posterior inner taenia ; 10, Anterior 

taenia; 11, Haustra (Sacculi). 

ally diminishes in cali- 
bre until the rectum is reached, where there is again an 
increase in size. The large bowel in its course describes 
an arch in the concavity of which the loops of the small 
intestine are located. From the right iliac fossa, the 
point of beginning, it runs upward through the right 
lumbar and right hypochondriac regions to the under 
surface of the liver, where it makes a curve, which 
is covered by the overlying liver ; passes then trans- 




The Large Bowel in Position. (Hartmann) 

a, Ascending colon ; 6, Transverse colon; c, Sigmoid flexure ; d, e, g, Mesocolon 
and mesentery ; h. Fascia covering inner pelvic muscles. 1, Central tendon (of dia- 
phragm) ; 2, Opening for the oesophagus ; 3, Bundles of muscle-fibre of the under 
surface of the diaphragm ; 4, Appendix vermiformis. 

8 



ANATOMY OF THE INTESTINES 9 

versely, with a somewhat upward tendency, onward be- 
tween the borders of the epigastric and umbilical regions 
into the left hypochondriac region, — near the spleen, 
about two vertebra higher than to the right, — where it 
again makes a curve and descends through the left lum- 
bar region and left iliac fossa, where it makes a sort of 
fold known as the sigmoid flexure ; it then passes down- 
ward and terminates at the anus. The large bowel is 
divided into various parts : the ccecum and appendix vermi- 
formis, the ascending colon, the transverse colon, the descend- 
ing colon, the sigmoid flexure, the rectum, and the anus. 

The caecum (blind pouch) is the largest segment of this 
section of the intestinal tract. It measures about two and 
a half inches both in its vertical and transverse diame- 
ters. It lies in the right iliac fossa on the right internal 
iliac muscle, with its end about the middle of Poupart's 
ligament. It is retained in position by the peritoneum, 
which passes over its anterior surface and sides, and 
posteriorly it is connected by loose areolar tissue with 
the iliac fossa. Occasionally it is almost surrounded 
with peritoneum, which then forms a mesocsecum. 

About the junction of the caecum and the ascending 
colon the ileum opens into the large bowel by a narrow, 
elongated, slit-like, aperture at right angles to the axis 
of the bowel. The mucous membrane forms here two 
semilunar valvular folds which project into the bowel 
and constitute the ileo-caecal valve, the valvida Bauhini. 
At each end of the orifice the valves coalesce, and are 
continued as a narrow membranous rido-e around the 
canal of the bowel for a little way, forming the frsena 
or retinacula of the valve. ' At the left extremity of the 



10 CONSTIPATION IN ADULTS 

slit the aperture is rounded ; at the right end it is narrow 
and pointed. When the caecum is distended, the borders 
of the valvular folds are closely approximated and any 
reflux prevented. 

At the lower and posterior portion of the caecum, there 
is found attached a small worm-like process, the appendix 




I leo -Cone Poio 
lno Caecai 



Ileum 



Orifice of Appendix Vermiformis 
(From Harrison Allen's Human Anatomy.) 

vermiformis. It is from three to six inches in length ; 
exceptionally it may be found longer ; thus Luschka saw 
one that had a length of twenty-three centimetres (about 
eighteen inches). Its diameter is about the size of a goose- 
quill. It opens into the caecum by a minute orifice at 
which an incomplete valve-like projection of the mucous 
membrane is sometimes found. 

The Ascending Colon : that part of the large intestine 



ANATOMY OF THE INTESTINES H 

lying on the right side of the abdomen between the crest 
of the ilium and the diaphragm. Continuous with the 
caecum and smaller than it, it mounts upward and some- 
what outward, to the right hypochondrium, passing in 
front of the lower half of the right kidney. Here it 
makes a turn, the flexura coli dextra sen hejiatica, runs 
horizontally and to the left, and terminates in the trans- 
verse colon. 

The right colic flexure is in contact with the lower 
border of the right lobe of the liver and partly also with 
the gall bladder. 

The ascending colon is covered anteriorly and on its 
sides with peritoneum and sometimes is completely 
invested by it, so that a narrow mesocolon is formed ; 
posteriorly it is usually covered by loose areolar tissue 
which connects it with the quadratus lumborum muscle 
and the kidney. It is thus retained in position. 

The Transverse Colon : the longest part of the large 
bowel passes transversely across the abdomen between 
the lower boundary of the epigastric and the upper 
boundary of the umbilical region to the left hypochon- 
drium, where it makes a turn, the flexura coli sinistra sen 
linealis, and passes downward to terminate in the de- 
scending colon. In its passage across the abdomen it 
describes somewhat of an arch, the concavity being 
directed backward toward the vertebral column. This 
is known as the transverse arch of the colon. 

This is the most movable part of the colon ; it is 
almost completely invested with peritoneum and is 
attached to the vertebral column by a large and wide 
duplicature of this membrane, the transverse mesocolon. 



12 



CONSTIPATION IN ADULTS 



It is in relation by its upper surface with the lower 
border of the right lobe of the liver, with the gall 
bladder, with the greater curvature of the stomach, and 
with the lower border of the spleen ; by its under surface 
with the small intestines ; by its anterior surface with 
the great omentum and the other constituent parts of 
the abdominal parietes. 

The Descending Colon passes downward through the 
left hypochondrium and the left lumbar region to the 
upper part of the left iliac fossa where it enters into 
the sigmoid flexure. 

The Sigmoid Flexure. — This is normally the narrowest 
portion of the large bowel and lies in the left iliac fossa. 

As usually described, the gut makes 
a double turn upon itself; begin- 
ning at the termination of the 
descending colon it curves 
upward, then descends and 
^ again makes an upward 




curve, the whole having 
the shape of the figure " g " — 
whence the name — and terminates 
in the rectum. According to Treves, 
however, this description, though 
classic, is erroneous; the flexure 
does not resemble the "§" Koma- 
num ; it has rather the figure of an 
omega — " 11." He describes it as 
follows : " The descending colon ends just at the outer 
border of the psoas. The gut here suddenly changes its 
direction ; it crosses the muscle at right angles and about 



(From Treves' Anatomy of 
the Intestinal Canal, etc.) 

C, Usual shape of the un- 
folded loop (adult) ; M, Ter- 
mination of descending colon; 
N, at the point of ending of 
the mesorectum. 



ANATOMY OF THE INTESTINES 



13 



midway between the lumbosacral eminence and Poupart's 
ligament. It now descends vertically along the left pelvic 
wall and may at once reach the pelvic floor. It then 
passes more or less horizontally and transversely across the 
pelvis from left to right and commonly comes into con- 
tact with the right pelvic wall. At this point it is bent 
upon itself, and, passing once more to the left, reaches 
the middle line and descends to the anus." Treves 
includes in his description of the flexure what is usually 
denominated the first segment of the rectum. The aver- 





A, Most usual arrangement of the 
loop when in situ. 



B, Rarer form of arrangement. 



age length of this portion of the bowel in the adult is 
about 17i inches. It is kept in place by a fold of peri- 
toneum, — the sigmoid mesocolon. The fold, however, 
is ample and permits of extensive movement on the part 
of this segment of the large bowel. 

The Rectum. — This is the terminal portion of the large 
bowel. It is narrower at its upper part than the sigmoid 
flexure, but dilates as it descends and, just before the 
anus, forms an ampulla, which may reach great size. 
The rectum, which varies in length from six to eiffht 
inches, is usually divided into three parts, — the upper, 



14 CONSTIPATION IN ADULTS 

the middle, and the lower portion. (As already stated. 
Treves recognizes but two segments, counting the first as 
part of the sigmoid flexure.) It begins at the left sacro- 
iliac symphysis, passes obliquely downward from left to 
right to the middle of the sacrum, making a gentle curve 
to the right. It regains the middle at this point and de- 
scends to the lower part of the sacrum and coccyx ; near 
the extremity of the latter bone it inclines backward to 
terminate at the anus, a buttonhole orifice, situated a 
little in front of the coccyx.. The upper part of the 
rectum is completely surrounded by peritoneum and 
connected with the sacrum behind by a fold of this mem- 
brane, which is known as the mesorectum. In front it is 
separated, in the male from the posterior surface of the 
bladder, and in the female from the posterior surface of 
the uterus and its appendages, by some convolutions of 
the small intestines. The middle portion is closely con- 
nected with the sacrum ; it is covered by peritoneum on 
its upper and anterior portions only. 

The Sphincters of the Anus. The external sphincter. — 
Like all sphincters, its purpose is to keep an orifice, 
that of the anus, closed. It consists of planes of 
muscular fibre which surround the anus. It is elliptical 
in shape and intimately adherent to the integument 
about the margin of the anus. It arises from the tip 
of the coccyx, and is inserted into the tendinous centre 
of the perineum, merging with the transverse perinei 
muscle. It has both voluntary and involuntary muscular 
fibres. 

The internal sphi?icter is a plane of involuntary 
muscular fibres about one-half an inch in length, which 



ANATOMY OF THE INTESTINES 



15 



surrounds the lower part of the rectum about an inch 
above the margin of the anus. 
A third sphincter does not exist. 1 




The External Sphincter of the Anus (and the Perineal Muscles in the 
Adult Male). (Hartmann.) 

1, The glutseus maximus; 2, Same, divided; 3, Deeper fasciculi of the same; 
4, Levator ani ; 5, 6, 7, Transversus perinei ; 8, Ischio-cavernosus ; 9, Bulbo-caverno- 
sus ; 10, External sphincter of the anus, a, Sacrum covered by its connective tissue ; 
b, Fascia; c, Point of origin of the muscles of the thigh. *, The latter shown to the 
right covered with fascia, se, Ligam. anococcygeum. 

Certain points in the structure of the large intestine 
are deserving of consideration. 

It strikes the eye of the beholder at once that the 

1 See Kelsey, Diseases of the Rectum and Anus. 



16 CONSTIPATION IN ADULTS 

large bowel does not present the smooth, even surfaces 
noted in the small intestine, but has a sacculated ap- 
pearance. This is due to the arrangement of the 
longitudinal muscular fibres in three large bands, from 
the beginning of the caecum at the appendix vermi- 
formis to the rectum. One of these bands, or taeniae, is 
posterior along the attached border of the bowel ; the 
anterior, the largest, is on the forward surface of the 
ascending and descending colon and sigmoid flexure, 
and on the under surface of the arch of the colon. 
The third, or inferior lateral band, is found on the inner 
surface of the descending and ascending colon, and on 
the under surface of the transverse section. These 
bands, being shorter than the rest of the intestine, draw 
it together, and so produce the appearance described. 
When they are dissected off, the bowel can be drawn 
out and its sacculation disappears. 

The mucous membrane, which is quite smooth and 
without villi, is thrown into crescentic folds, Plicce 
Sigmoidece, which project forward like valves between 
the sacculi. Their arrangement is such that their free 
borders are not all in the same direction. 1 

The rectum is not sacculated, but smooth and cylin- 
drical, the taeniae being wanting here. The mucous 
membrane of the rectum is thicker, more vascular, of 
darker color, and but looseh* connected with the muscular 
coat. When the rectum is collapsed, its mucous mem- 
brane is thrown into folds which are in apposition with 
each other, and obliterate, as it were, the lumen of the 
bowel. When the rectum is distended, the folds disappear. 

1 See chapter "Physiology of Peristalsis." 



ANATOMY OF THE INTESTINES 17 

Houston described as valves of the rectum folds of 
the mucous membrane found protruding into it, and 
ascribed to them the function of holding up the faeces, 
i.e. preventing its constant descent, and consequently 
constant irritation of the sphincter. They were said to 
be present in all persons, but to vary in number and 
location. It has, however, been disputed, and the weight 
of authority is against their existence, as a rule. This 
much, however, is positive, that even where such pro- 
truding folds do exist they have no valvular function ; 
the rectum has no need of valves. Occasionally a large 
fold of mucous membrane is found, extending into the 
lumen of the tube ; Kohlrausch described such a fold, 
which he calls plica transversalis recti, and it has been 
seen by others. 

About the level of the internal sphincter five or six 
little semilunar valves are noted, with their con- 
cavities directed upward toward the colon. 1 They form 
an irregular line around the canal. They are thus 
described by Dr. Horner : " The mucous coat of the 
rectum is thick, red, and fungous, and abounds in mu- 
cous lacunae and glands. It is laid smoothly above, 
and below it is thrown into superficial longitudinal 
folds called columns. At the lower end of the wrinkles 
between the columns are small pouches from two to 
four lines in depth, the orifices of which point upward; 
they are occasionally the seat of disease, and produce, 
when they are enlarged, a painful itching. " 2 

1 Handy, W. R., Text-book of Human Anatomy, Philadelphia, 1854. 

2 Special Anatomy and Histology. Eighth Edition, Vol. II. Phila. 
1857. Bodenhammer, "Observations on the Normal Sacculi of the Anal 
Canal," etc., Medical Record, May 26, 1888. 



18 



CONSTIPATION IN ADULTS 



The function of these little pouches, Saeculi Horneri, 
is apparently to collect mucus which may be required 
to lubricate the moving faeces, and thus facilitate its 
expulsion. 




(From Handy, Text-book of Human Anatomy.) 

Represents a section of the anus and rectum, showing the rectal pouches. 
aa, Columns of the rectum ; bb, Rudiments of columns ; c, Internal sphincter divided ; 
d, External sphincter divided ; ee, Folds of skin on the nates; /, Pouches ; g, Bristles 
in the pouches. 

Arteries. 

I. Pancreatico-Duodenalis, branch of the gastro- 
duodenalis, branch of the hepatic, branch of the 
cceliac axis, supplies the first part of the duo- 
denum. 
II. Superior Mesenteric Artery : a large vessel aris- 
ing from the abdominal aorta a little below the 
cceliac axis. It passes forward between the pan- 
creas and transverse portion of the duodenum 
and descends between the layers of the mesentery 
to the right iliac fossa, where it terminates, con- 
siderably diminished in size. It supplies the 



ANATOMY OF THE INTESTINES 19 

whole length of the small intestine except the 
first part of the duodenum. It also supplies 
the caecum, ascending and transverse colon. 

Branches: Vasa intestini tenuis, fifteen or twenty 
branches, arising from the convex side of the 
artery. They anastomose with each other in 
a series of arches which become smaller and 
more numerous as they approach the small in- 
testines, to which they are finally distributed. 

Inferior pancreatico-cluodenal is distributed to the 
transverse and descending portion of the duo- 
denum ; it anastomoses with the pancreatico- 
duodenal. 

Ileo-colic, distributed to the lower portion of the 
ileum, caecum, and vermiform appendix. Anas- 
tomoses with branches from the inferior mesen- 
teric artery. 

Colica dextra to the ascending colon. 

Colica media to the transverse colon. 
The artery is accompanied in its course by the 
superior mesenteric vein, and is surrounded by 
the superior mesenteric plexus of the sympathetic 
nervous system. 
III. Inferior Mesenteric Artery arises from the 
left side of the abdominal aorta just before the 
point of bifurcation. It is not so large a vessel 
as the superior mesenteric artery. It supplies 
the descending colon, the sigmoid flexure, and 
the greater part of the rectum. 

Branches : Colica sinistra to the descending colon. 

Arteria sigmoidea to the sigmoid flexure. 



20 CONSTIPATION IN ADULTS 

IV. Hemorrhoidals Superior is the continuation 
of the inferior mesenteric artery from the iliac 
fossa downward. It descends between the meso- 
rectum to the rectum, and at about its mid- 
dle divides into two branches which descend 
on either side of the rectum, where they divide 
into several smaller branches, which are dis- 
tributed to the muscular and mucous coat of 
this section of the bowel near its lower end. 
These anastomose with each other, with the 
middle hemorrhoidal and inferior hemorrhoidal 
arteries, and with branches from the internal 
iliac and internal pudic arteries. 
This artery is accompanied by the inferior 
mesenteric vein, and is surrounded by the 
inferior mesenteric plexus of the sympathetic 
nervous system. 

V. Middle Hemorrhoidal Arteries. Branches of 
the internal iliac, distributed to the anterior 
part of the rectum. 

VI. External Hemorrhoidal Arteries. Two or 
three small arteries — branches of the internal 
pudic, distributed to the muscles and integu- 
ment about the anus. 

Veins. — Superior mesenteric vein, 

Inferior mesenteric vein, unite with others to 
form the portal vein. 

Nerves of the Intestinal Tract. — The nervous system 
of the intestinal tract is almost altogether part of the 
great sympathetic system. The nerve filaments and 



ANATOMY OF THE INTESTINES 



21 




Ret. 



Diagram to illustrate the Nerves of the Alimentary Canal in the Dog. 
Foster, Human Physiology. 

The figure is for the sake of simplicity made as diagrammatic as possible, and does 
not represent the anatomical relations. 

Oe to Ret. — The alimentary canal, oesophagus, stomach, small intestine, large intes- 
tine, rectum. 

L. V. Left vagus nerve ending on front of stomach, r.l. recurrent laryngeal nerve 
supplying upper part of oesophagus. R. V. right vagus, joining left vagus in 
oesophageal plexus, oe. pi., supplying the posterior part of stomach and con- 
tinued as R' . V . to join the solar plexus, here represented by a single ganglion 
and connected with the inferior mesenteric ganglion (or plexus) m. gl. — 
a. branches from the solar plexus to stomach and small intestine, and from the 
mesenteric ganglion to the large intestine. 

Spl.maj. Large splanchnic nerve arising from the thoracic ganglia and rami com 
municantes r.c. belonging to dorsal nerves from the 6th to the 9th (or 10th). 

Spl. min. Small splanchnic nerve similarly arising from 10th and 11th dorsal nerves. 
These both join the solar plexus and thence make their way to the alimentary 
canal. 

C.r. Nerves from the ganglia, etc., belonging to 11th and 12th dorsal and 1st and 
2nd lumbar nerves, proceeding to the inferior mesenteric ganglia (or plexus) 
m. gl. and thence by the hypogastric nerve n. hyp. and the hypogastric plexus 
pi. hyp. to the circular muscles of the rectum. 

l.r. Nerves from the 2nd and 3rd sacral nerves, S.2, S.3 (nervi erigentes) . proceeding 
by the hypogastric plexus to the longitudinal muscles of the rectum. 



22 CONSTIPATION IN ADULTS 

plexuses are derived more directly from the following 
plexuses, which are themselves but part of the great 
solar, or epigastric, plexus : 

The superior mesenteric plexus, 
The inferior mesenteric plexus, 
The aortic plexus, 
The hypogastric plexus. 

The superior mesenteric plexus accompanies the su- 
perior mesenteric artery into the mesentery, and there 
divides into a number of plexuses which follow the 
branches of the artery to the parts supplied by it ; 
namely, the small intestines, the cecum, the ascending 
and the transverse colon. 

The inferior mesenteric plexus (which originates more 
directly from the aortic plexus) accompanies the rami- 
fications of the inferior mesenteric artery to the parts 
supplied by it, — the descending colon and the sigmoid 
flexure. 

The superior hemorrhoidal plexus (which also is 
part of the aortic plexus) supplies with nerve filaments 
the upper part of the rectum. 

The inferior hemorrhoidal plexus, part of the hypo- 
gastric plexus, distributes itself over the inferior portion 
of the rectum and there unites with the ramifications 
of the superior haemorrhoidal plexus. 

These plexuses, after they have entered into the 
intestinal structure, divide into two distinct layers, 
which surround the intestinal tissues in every direction. 
The first layer is located between the longitudinal and 
the circular layers of muscular fibres, and constitutes the 



ANATOMY OF THE INTESTINES 23 

plexus myentericus of Auerbach. The second layer is 
found between the mucous membrane and the sub- 
mucous tissue, and is the plexus of Meissner. These 
plexuses are formed by a network of fine non-medullated 
nerve fibres, with ganglia and ganglionic cells located 
at various points in the network. There are communi- 
cating branches between the two layers. 




Plexus of Auerbach, between the Two Layers of the Muscular Coat of 
the Intestine. (Cadiat.) 

The bowels have no direct connection with the cerebro- 
spinal system ; indirectly, however, they have such con- 
nection. As has been said, all the various plexuses above 
recounted are more or less part of the great solar 
plexus, and this receives the terminal extremity of the 
right pneumogastric nerve. 

Through the solar plexus the intestines are in com- 
munication with the various organs of the body ; for. 



24 



CONSTIPATION IN ADULTS 



besides the terminal portion of the right vagus nerve, 
this plexus receives also the ends of the splanchnic 
nerves, the greater and the lesser, which are derived 

from the thoracic 




gan- 



sympathetic 
glia. 

Only the rectum 
and the anus are in 
direct communica- 
tion with the cere- 
brospinal system. 
Besides thebranches 
of the great sym- 
pathetic system al- 
ready named, these 
parts receive nerve 
filaments from the 
sacral plexus of the 
spinal cord. The 
part, however, that 
is most abundantly 

Plexus of Meissner from the Submucous Coat Slippliedwithnerves 
of the Intestine. (Cadiat.) n ,-, ^ 

irom the cerebro- 

a, Cavity of tubular glands or crypts; b, one of the 
lining epithelial cells ; c, Interglandular tissue ; d, Lym- Spinal System, is the 
phatics. , , . 

external sphincter. 

1. The inferior hoemorrlioidal nerve (usually a branch 
of the pudic) is distributed to the external sphincter 
and to the integument around the anus. 

2. The posterior branch of the superficial perineal nerve 
passes to the back part of the ischio-rectal fossa and 
distributes filaments to the sphincter ani and the integu- 



ANATOMY OF THE INTESTINES 



25 



ment around the anus: these unite with the inferior 
hemorrhoidal nerve. 

Moreover, the integument around the anus with which 



Bulbo-cavernosus 



Superficial triangular ligament 
Ischio-cavernosus 



Muscles of thigh 




Gluteous Maximus 
Tuberosity of Ischium 
Sacro-sciatic ligament 
Levator ani 
Sphincter ani Superficial transverse perinei 

The Male Perineum. (From Morris' Text-book of Human Anatomy.) 

1, Inferior pudendal nerve; 2, Superficial perineal nerve; 3, Inferior hemorrhoidal 
nerve; 4, Cutaneous branch of fourth sacral. 



the sphincter is in intimate relation, and the accessory 
muscles of the latter, receive filaments from various 
branches of the great sacral plexus, the cutaneous from 



26 CONSTIPATION IN ADULTS 

the fourth sacral, the inferior pudendal, and the anterior 
branches of the superficial perineal. 

The bowels hang rather loosely attached to various 
parts in the abdominal cavity. They are supported and 
kept in place by the muscles and other structures form- 
ing the anterior and the posterior abdominal walls. 

Luschka. Die Bauchorgane des Menschen. 

Gray. Anatomy — Descriptive and Surgical. 

Treves. The Anatomy of the Intestinal Canal and Peritoneum. 

Hunterian Lectures. 
Klein, E. Atlas of Histology. Elements of Histology. 
Mathews. The Diseases of the Rectum, etc. 
Kelsey. Diseases of the Rectum and Anus. 
Houston. Dublin Hospital Reports, 1830 (Vol. V.). 
Kohlrausch. Anat. et Physiolog. der Beckenorgane. Leipzig, 

1854. 



CHAPTER II 

FLATUS (nNEY2I2, WIND, GAS) 

In the course of the process of digestion in the intes- 
tinal tract, by reason of the breaking up of the various 
alimentary matters ingested and their elaboration into 
assimilable material, gases are developed in the stomach 
and in the intestines. They were primitively divided 
by Van Helmont 1 into two groups, — the inflammable and 
the non-inflammable, the gases of the large bowel consti- 
tuting the former, those of the stomach and the small 
intestines the latter group. This same subdivision was 
adopted by Priestley. 

The flatus thus formed is constituted by various gases : 
carbonic acid gas (C0 2 , carbon dioxide) ; carburetted 
hydrogen (CH 4 , methane, marsh gas) ; nitrogen (N) ; 
hydrogen (H) ; sulphuretted hydrogen (H 2 S [HS 2 ], hydro- 
gen sulphide). The last is found normally in the 
intestines only. 2 There is some difference of opinion in 
regard to carburetted hydrogen, whether it is a normal 
constituent of the flatus or not."' 

1 Tract, de Flatibus, 27. 

2 In pathological conditions of the stomach, in dilatation with decided 
stagnation, it is also found in the stomach and readily recognized in the 
withdrawn stomach contents by the well-known test. 

3 Planer, Sitzungsberichte d. Akadem. d. Wissenschaften zu Wiej), Vol. 
XLII. Ruge, Ibid. Vol. XLIV. 734. Chemisch. Centralblatt, 18(52. 347. 
Nowack und Brautigam, Muenchener Mediz. Wochenschr. 1890. 

27 



28 



CONSTIPATION IN ADULTS 



The gases vary of course in volume, depending much 
upon the character of the food that is taken. Thus it 
is well known that the leguminous seeds, as peas and 
beans, give rise to a greater proportion of flatus, espe- 
cially of carburetted hydrogen, than do other articles 
of food. 

In addition to the gases thus developed, a certain 
amount of the volume of the flatus is derived from extra- 
neous sources ; a certain amount of air is swallowed with 
the food in the act of deglutition and a quantity of car- 
bonic acid gas (perhaps the greater part) is diffused into 
the intestines from the blood-vessels. 1 

The following table of Planer gives the volumes of the 
various gases as found by him in the stomach, in the 
small intestines, and in the large bowel: 



Gases, in Volume, 
Per Cent. 



C0 2 
H . 
CH 4 
N . 
. 
SH 2 



Stomach. 


Small 
Intestines. 


Large Bowel. 


20.79 


38.83 


16.23 


32.27 


30.64 


34.80 


6.71 


27.58 


4.04 


35.55 




12.88 


75.50 


38.22 
0.37 


79.73 


31.63 

0.05 

Trace 


69.36 


50.20 
Trace 2 



Ruge 3 found the flatus of the large bowel collected per 
anum, regard having been had to the influence of diet, 
constituted as follows : 

i Foster, Physiology. Landois and Sterling, Physiology. Charles, S. J., 

British Medical Journal, 1885, February, " The Sources, etc., of Carbonic 
Acid." 

2 Loc. cit. s Loc. cit. Foster, Physiology. 



FLATUS (IINEYSIS, WIND, GAS) 



29 





Mixed Diet. 


Leguminous 
Diet. 


Meat Diet. 


co 2 


40.54 

17.50 
19.77 

22.22 
Trace only 


21.05 

18.96 

55.94 

5.03 


8.45 


N 

CH 4 

H 

SH 9 


64.41 

26.45 

0.69 







The flatus is an important factor in the proper func- 
tioning of the bowels ; it stimulates peristalsis, tends to 
keep the intestines distended, and contributes much to the 
looseness of the ingesta and of the faecal matter. 1 

Under normal conditions the flatus is removed from 
the intestines by reabsorption by the blood-vessels, and 
by discharge through the* rectum. 

When from any reason this disposition of the flatus 
is interfered with, it accumulates, augments in volume, 
distends the belly, and not infrequently is the cause of 
spasmodic pains, more or less severe, therein. 

Its presence in larger volume is recognized by the char- 
acteristic tympanitic sound given forth by the abdomen 
upon percussion. The accumulation of flatus in habitual 
constipation, where it is mainly confined to the large bowel, 
is never so great as in the acute forms of constipation,* 2 
where both accumulation and exaggerated formation with 
greater distension of volume are favored. Occasionally 
the flatus may itself become the cause of a constipation. 

When faecal vomiting occurs, the abnormal accumu- 
lation and production of flatus is the chief factor thereof. 

1 Nowack and Brautigam, loc. cit. 

2 The conditions favoring the free development and action of the patho- 
genic bacteria. 






CHAPTER III 

INTESTINAL PERISTALSIS 

Just as they differ in anatomical appearance, so do 
the two sections of the intestinal tract differ in function. 
Whilst it is the province of the small intestines to 
elaborate the chyme coming from the stomach and such 
other parts of the food taken as have as yet undergone 
but little change into substances that can be readily 
assimilated by the system, and to absorb these from 
the moving mass of matter as it progresses on its 
downward journey, the large bowel collects the indi- 
gestible residue, and after extracting what little of nutri- 
tive material remained therein, propels it onward and 
downward and expels it from the body. 

In the performance of its functions the intestinal 
tract makes a series of movements, known as peristalsis 
(iTepicrTeWco, to send around, to surround), by which 
the food materials are carried onward and downward. 
These movements are vermicular in character, and are 
produced by the contractions of the several layers of 
muscular fibres clothing the intestines. There is a con- 
traction of the circular muscular coat which travels 
lengthwise and downward; following it, a contraction 
of the longitudinal muscular fibres, which also travels 
lengthwise and downward. The circular layer of muscu- 
lo 



INTESTINAL PERISTALSIS 31 

lar fibres being the largest, its contractions are the most 
powerful and the most effective. By them the lumen of 
the tube is constricted at that particular point and an 
upward escape of the contents prevented ; at the same 
time a pushing downward force is exerted. The contrac- 
tion of the longitudinal fibres shortens the special section 
of the intestine, and thus materially aids the forward and 
downward transport. 

Small Intestines. — The peristaltic action of the small 
intestines begins at the duodenum. It is not a continuous 
movement, i.e. that, beginning at the duodenum, it con- 
tinues onward in regular course without interruption 
until it has reached the ileo-csecal valve. It continues 
for a short distance, and beyond that for another distance 
everything is quiescent ; heyond that again, activity. 
Frequently several distinct sections or loops, lying side 
by side, are contemporaneously in action, with perfectly 
quiescent portions or loops intervening between them. 
All at once the active sections will become quiescent, 
whilst the previously immobile parts will become active. 1 

The peristaltic movements of the small intestines can, 
according to Nothnagel, 2 be divided into two groups : the 
first, already described, the vermicular action, alternate 
contraction and dilatation and lengthening and shorten- 
ing of the tube. With this a change of position of the 
active loop or loops may occur, making a sort of rolling 
motion. The second, observed in the small intestines 
only, is a to-and-fro, pendulum-like movement. It is 
tli ought that by this motion the various constituents 

1 Nothnagel, Beitriige zur Physiologie u. Pathologic des Darmes. 

2 Ibid. 



32 COXSTIPATIOX IN ADULTS 

of the chymus are more thoroughly shaken together, and, 
furthermore, the chyme, which is acid, 1 is brought into 
more immediate contact with the secretions of the intes- 
tinal parietes, which are alkaline. 2 

This is the more plausible, as during this special 
movement there is no carrying forward of intestinal 
contents, they remaining in the parts in motion even 
though this continue ■ for quite a length of time. 

This oscillatory movement is produced more particu- 
larly by the action of the longitudinal muscular fibres. 3 

The movements of the small intestines are slow. 

Large Intestines. — Almost all that is convertible into 
assimilable material having been properly prepared and 
almost altogether absorbed, the indigestible residue is 
discharged into the large bowel, into the caecum. Here 
putrefactive changes, brought about by apparently a 
specific microbe, 4 take hold of the residue of the albu- 
minous matter that has passed over and it is broken 
up into its ultimate products, — indol, skatol, etc. Here 
also what little of assimilable material has been carried 
over is absorbed. Then by peristaltic action, which is 
the same as in the small intestines, the residuum is 
pushed gradually onward from sacculus to sacculus, 
assuming more and more the color, form, and consistence 
of normal fseces, until, when it arrives at the sigmoid 
flexure, it is the fseces ready for expulsion. 

1 Macfadyen, Nencki, and Sieber, Archiv f. experiment. Pathologie a. 
Pharmacologic, Vol. 28, Heft 1 and 2. 

2 Ibid. 

3 Foster, Physiology. 

4 Bienstock, Zeitschrift /. klin. Medizin, 1884. Macfadyen, Nencki, and 
Sieber, loc. cit. 



INTESTINAL PERISTALSIS 33 

The peristaltic movements in the large bowel are much 
slower than in the small intestines. 

The time occupied in the passage of the small intestines 
is three to four hours ; of the large bowel, from ileo- 
csecal valve to rectum, it is twelve hours. 

As to the causes producing these movements, this much 
can be said : An impulse to movement is undoubtedly 
communicated by the pyloric portion of the stomach, and 
by the chyme projected into it, to the duodenum. That 
the chyme does per se excite peristaltic action has been 
established by Nothnagel. 1 The discharge of the bile 
adds to the impulse. Then the acid chyme coming in 
contact with the alkaline secretions of the intestinal 
walls and with the various other secretions poured into 
the intestinal canal, chemical changes are instituted and 
gases developed, which also, as has been experimentally 
observed, have a stimulating effect on the bowel. In 
addition to all this, we have the influence of the coarse 
particles in the chyme. In the large bowel, though un- 
doubtedly a certain amount of impulse or stimulus is 
received from the smaller intestine, still the principal 
factor of the peristalsis here are the coarse particles of the 
indigestible residue. 

It has been a question with physiologists, and one that 
is not yet definitely settled : Is the peristalsis due to 
nervous action or is it the result of muscular irritation ? 
It is possible that the peristalsis is entirely due to muscu- 
lar irritability, i.e. that the irritation of the mucous mem- 
brane is communicated to the underlying cell of the 
muscular coat, and thence passed from one cell to 

1 Loc. cit. 



34 CONSTIPATION IN ADULTS 

another ; experimental study and clinical observation, 
however, indicate clearly that it is the result of nervous 
action. 1 

This view is certainly more in harmony with physio- 
logical processes in other parts of the body, and is more 
than confirmed by the abundant nerve supply furnished 
the intestines by the great sympathetic system as already 
described. 

The cerebrospinal system is ordinarily not interested in 
this peristalsis. It always proceeds without any percep- 
tion thereof on the part of the cerebrum ; only when it 
becomes abnormal, when it becomes spasmodic, either 
from excess of local irritation or by reason of an irritant 
impulse that has been sent down from the cerebrum 
through the vagus, do we become conscious, painfully so. 
of the movements going on within us. 

Upon the basis here set forth there are no contradic- 
tions, and the rather varied clinical phenomena observed, 
such as the production of diarrhoea by sudden mental 
shock or impression, are readily explained. 

From the results of various experimental observations 
it has been assumed that the sudden stoppage of the 
circulation would produce increased peristaltic action, and 
that this was directly due to the carbonic acid which 
accumulated in the blood. However, the investigations 
of Van Bra-am Houckgeest 2 and of Nasse 3 have shown 
that just the reverse is true : venous stasis and accumula- 
tion of C0 2 have an inhibitory influence, arrest peristalsis, 

1 Nothnagel, loc. cit. 

2 Pflueger's Archiv, Vol. VI., 1872. 

8 Beitrage z. Physiolog. d. Darmbewegungen, 1866. Foster, Physiology- 



INTESTINAL PERISTALSIS 35 

whilst increased oxygenation makes the movements more 
powerful. 

The gases developed in the intestinal tract, by keeping 
the bowels moderately distended, greatly facilitate the 
passage through them, from pylorus to rectum, of the 
chyme and residuary bolus. 1 

Defecation. — As can be seen from the configuration of 
the sigmoid flexure, whether it be of the form described 
by anatomists generally or it have the shape noted by 
Treves (upon careful reading of his description and atten- 
tive inspection of his drawings, it does not require a great 
stretch of the imagination to see an "g" romanum 
[rather a sigma] in the omega), it is evidently intended 
for the accumulation of faeces ; and this is truly its 
purpose. The fully formed faeces accumulate in the 
flexure and are held there ready to be discharged. Ac- 
cording to the description of O'Beirne, 2 there is a narrow- 
ing at the point of junction of the sigmoid flexure and 
the rectum — O'Beirne's sphincter. But even if this be 
disputed, it is nevertheless readily understood how the 
faeces can collect therein. As already stated, the move- 
ments of the large bowel are very slow, and there is 
but little vis a tergo. The sigmoid flexure is of large 
capacity ; moreover, lying as it does on the sacrum and 
bladder, it is supported, held up, and the faeces kept from 
falling down. The rectum is always free from faeces, as 
was stated by O'Beirne, and as I have amply convinced 
myself. Its walls lie ordinarily in apposition and it thus 
forms an additional support for the faecal masses gathered 

1 See Chapter II. 

2 New Views on the Process of Defecation, etc., 1834. 



36 CONSTIPATION IX ADULTS 

in the flexure. The pouch frequently forms an exception 
to the rest of the rectum, in that it may contain some 
faeces, whilst the balance of the " straight tube " is empty. 

The anus, the terminal extremity of the intestinal 
tract, is guarded by the external sphincter, which is 
habitually in a state of tonic contraction, which can 
be increased or diminished by a stimulus applied to it, 
either internally or externally. 

This contraction is perhaps altogether due to the action 
of a special nerve centre, situated in the spinal cord. 
Experimental investigation has shown that this centre 
is not situated higher than the lumbar region of the 
cord. Increased irritability or diminution of the same 
in this centre is followed by increased or diminished 
contraction of the sphincter. This centre is again under 
the control of the higher centres in the brain. By the 
action of the will, by emotions.* the centre may be 
inhibited and a relaxation of the sphincter result, or its 
irritability may be heightened and the sphincter become 
more firmly contracted. The sphincter can be acted 
upon directly by the cerebrum and a strong contraction 
thereof effected. However, under circumstances, the 
energetic peristalsis may overcome all efforts of the 
will. Irritation of the pedunculus cerebri and downward 
along the spinal cord produces a contraction of the exter- 
nal sphincter. 1 

As long as the fseces remain above the rectum, no 
perceptible sensations are conveyed to our mind. As 
soon, however, as the faeces pass into the rectum and 
reach about the middle thereof, an irritation of the nerve 

1 Landois, Lehrbuch der Phvsioloffie des Menschen, 1880. 



INTESTINAL PERISTALSIS 37 

filaments traversing the mucous membrane is set up, — a 
notification, as it were, is sent to us ; we become con- 
scious of its presence whilst at the same time the 
sphincter is more firmly contracted. 

The process of defecation would therefore be about as 
follows : The peristalsis in the large bowel becomes more 
energetic, a quantity of faeces descends into the rectum 
pushed onward by the vis a tergo of the moving masses, 
a notification is at once sent in, whilst the sphincter 
becomes firmly contracted. Ready for the evacuation, 
by the command of the will (automatically, according to 
some), the sphincter centre in the cord is inhibited and 
a relaxation of the muscle results. The sudden emptying 
of the rectum creates a vacuum, the air rushes in, the 
rectum is kept open, and fasces from the flexure follow. 

There is a further and more powerful factor concerned 
in this process ; namely, the voluntary, forcible drawing 
in of the wall of the abdomen, — the abdominal pressure 
(Bauchpresse) which we call in to aid the involuntary 
mechanism hitherto considered. An inspiratory act is 
begun, the lungs are moderately filled, then the glottis 
is closed ; the diaphragm is in the inspiratory position, 
i.e. descended, and the abdominal walls are strongly 
drawn in. By this means we exert a powerful pressure 
upon all the abdominal organs, upon all parts of the 
colon ; its contents are pressed out, as it were, pushed 
into the flexure, and that which had been previously 
stored there made to descend into the rectum. Even 
if we are inclined to hold that the sigmoid flexure is 
removed from the influence of the pressure exercised by 
the abdominal walls (which I doubt very much), the 



88 CONSTIPATION IN ADULTS 

expression of the other parts of the colon, the increased 
peristalsis naturally excited, and the dilatation of the 
rectum by the inrushing air are amply sufficient to effect 
a further descent of the faeces. 

This pressure with the abdominal walls can be exercised 
with greater or less force, according to the needs of the 
hour. Greater force is, of course, demanded if the peri- 
stalsis be slow, feeble ; if the tonicit} 7 of the intestine be 
impaired ; if the faeces be hard and dry, either from over 
inspissation or from a lack of sufficient mucous secretion ; 
much less force, when all things are normal. 

By the movements described the perineum is pressed 
out, the anus is dilated, and the sharp bend in the lower 
part of the rectum somewhat straightened, and this part 
brought more into line with the rest of the canal. The 
levator ani muscle, which forms a support for the pelvic 
organs during the act of straining, assists also in the act 
of defecation ; by its contraction it draws the anus and 
the marginal extremity of the rectum upward, strips it, 
as it were, over the descending column of faeces, and thus 
hastens its discharge. It also aids in retracting the soft 
parts that have been pushed out in straining. 1 

1 Flint, A Text-book of Human Physiology, 1888. Landois, Lehrbuch 
der Physiologie des Menschen. Carpenter, Human Physiology. Foster, M., 
A Text-book of Human Physiology, 1891. 



CHAPTER IV 

FAECES 

A normal omnivorous individual discharges from 
four to six ounces of faeces in the twenty-four hours. 
The quantity varies with the quantity of food that is 
taken, being larger in gross eaters. It varies also with 
the character of the food that is taken. A diet of which 
vegetables form the major part will, naturally, give a 
larger quantity of faeces than one which is almost 
entirely made up of nitrogenous substances. These latter 
are taken up almost altogether into the system, leaving 
but little detritus. 

Of the quantity thus discharged, seventy-four per cent 
is water, and twenty-six per cent solid constituents. This 
proportion is requisite for the natural and easy discharge 
of the excrement. When the proportion of water falls 
below fifty per cent, then the matter is moved with 
greater difficulty, and consequently much more slowly, 
to the outlet ; whilst should it fall below twenty per 
cent it cannot be moved at all, even with the muscular 
power of the intestine at the normal, and accumulation 
results. 

Ordinarily the faeces are a homogeneous mass of fair 
consistence and of sausage-like shape. The consistency, 
like the quantity, depends upon the food that is taken ; 
it is firmer with an abundant meat diet, whilst it is 

30 



40 CONSTIPATION IN ADULTS 

more like pap when vegetables form the main article of 
sustenance. 

The color is usually a yellowish or dark brown, and is 
due chiefly to biliary pigment. This also varies some- 
what with the character of the diet. A milk diet gives 
a light yellow stool. Certain articles of food, rich in 
coloring matters, may give it an unusual coloration. 

The odor is characteristic, and is the result of the 
putrefactive processes that go on normally in the large 
bowel as described. 

The reaction, though generally alkaline, varies also 
with the diet. With vegetarians, or with those who live 
mainly on vegetable food, it is acid ; with a meat diet, 
or with the average admixture of nutritive material, it 
is alkaline. 

The faeces consist of residuary indigestible matters, 
of the products of destructive cell metamorphosis and of 
chemical change, and of substances gathered up in the 
intestinal tract. The extraneous matters are plant cells, 
vegetable fibre, starch grains, muscle fibre, connective 
tissue, and fat. From the intestinal tract there are 
gathered up epithelium, round cells, mucus, and bacteria ; 
bile salts and bile pigment. In addition, they contain 
crystalline salts, the products of the digestive process : 
the ammonia-magnesium phosphate, neutral phosphate of 
lime, lime salts colored yellow by bile pigment, and oxalate 
of lime. 

Mucine is a regular constituent of the faeces. 

Albumen is never fonnd. 

A microscopical examination of the faeces is always 
advantageous and is readily made. A minute quantity 



FAECES 



41 



of fseces is rubbed up on a slide, — if it be too dry a drop 
of water can be added, — covered with a cover glass 
and put under the microscope. Normal faeces from the 
ordinary mixed diet will present a picture, like this : 




Normal F^ices. (From Jaksch, Klinische Diagnostik.) 

a, Muscle fibres; b, Connective tissue; c, Epithelium; d, White blood-corpuscles; 
e, Spiral cell (vegetable cell); f-i (inclusive) vegetable cells of diverse forms; 
k, Triple-phosphate crystal ; between these various elements an enormous mass of 
micro-organisms; I, Diatoms. 

In the stools of persons living almost exclusively upon 
a meat diet but very little or no vegetable residue, as 
plant cells or vegetable fibre, will be found. 

Such an examination will disclose to us any foreign 
bodies that may be present as helminthes or the products 
of pathological processes going on in the intestine. 1 

1 Flint, Text-book of Human Physiology. Von Jaksch, Klinische Di- 
agnostik. Landois, Lehrbuch der Physiologie des Menschen. Rosenheim, 
Pathologie u. Therapie der Verdauungskrankheiten, Theil II. 



CHAPTER V 

DEFINITION; ETIOLOGY; CLASSIFICATION 

Constipation — delayed evacuation of the bowels — 
is said by many to be but a comparative term, and what 
might be considered constipation in the one is normal 
habit in the other. 1 They hold this for the reason that 
we see persons who have a stool but once in three or 
four days, a week, or even longer, in the enjoyment of 
good health, and I myself saw a woman who had but a 
limited evacuation once a month — every thirty days a 
midwife came to her house and scooped out the accumu- 
lated and hardened faecal masses from the rectum — and 
still she did not, apparently, suffer much from this reten- 
tion. Retarded evacuation can therefore, according to 
these authorities, be called constipation only when morbid 
symptoms manifest themselves concomitantly with it. I 
am, however, of a different opinion. It is the consensus 
of physiologists that every normal person should have an 
evacuation once in twenty-four hours, or, taking into con- 
sideration that our food at the present day is freer 
from coarse particles, and that therefore peristalsis is 
slower, at least once every other day. 2 I, therefore, 
regard every person who does not have a full, free evacu- 

1 Chambers, Digestion and its Derangements. Henoch, Unterleibskrankh. 
Nouveau Dictionnaire de Medecine et de Chirurgie pratique. 

2 Flint, Landois, Foster (Physiology) . 

42 



DEFINITION; ETIOLOGY; CLASSIFICATION 43 

ation once in three clays at the furthest, without, of course, 
the aid of extraneous measures, as constipated, even 
though he present no disturbances of normal function. 
It is possible that certain of the fluid or solid constituents 
of the body have suffered a change in some of their con- 
stituent elements, either by the addition of a foreign 
element or by the subtraction therefrom by chemical 
metamorphosis of a native one ; a change, however, which 
escapes our observation because our knowledge of the 
intimate normal constitution of these bodies is still far 
from complete, and our methods of examination and the 
mechanical aids thereto are still defective. Moreover, it 
cannot be maintained that in case of sickness from other 
causes in such a person, that the constipation will not 
make itself felt to the detriment of the patient. It can- 
not be maintained that the constipation does not render 
the person particularly prone to a certain category of 
ailments, or even predisposed to all the ailments that 
flesh is heir to. Even if the foregoing be disputed (which 
it cannot), it can only be said that a tolerance has been 
established ; that the system has become habituated to 
this state even as the mountaineers of Styria have become 
accustomed to arsenic, and such an individual can eat 
with gusto an amount of the drug that would, with us, 
suffice to send a regiment of soldiers to the bourne whence 
no traveller has as yet returned. 

What is constipation ? Constipation means that al- 
though a sufficient quantity of food is taken and digested 
fully, there is, nevertheless, a ivant of normal discharge of 
the indigestible residual matters and the other matters 
therein gathered up from the boivel. 



44 CONSTIPATION IN ADULTS 

This definition excludes, and what I regard as very 
properly, the long-delayed defecation resembling consti- 
pation, which we find as one of the symptoms of 

Stricture of the sesophagus, or obstruction of the same 

by tumors from without; of 
Ulcer of the stomach ; of 

Cancerous disease of the stomach about the pylorus ; of 
Non-malignant stricture of the pylorus; of 
Ulcer of the duodenum. 

In all these morbid states very little food is usually 
taken, or rather can be taken ; what is taken is of con- 
centrated nutritive form, with little or no residual matter, 
and even of that little which is ingested, a considerable 
portion is usually vomited. If much or coarse food is 
taken, it is certainly almost altogether rejected. It is very 
evident, therefore, that the condition is not one of con- 
stipation, but rather an absence of material to be dis- 
charged. For the same reason, I exclude the absence of 
alvine discharges in starvation, inanition, although some 
authors class it and describe it under the head of consti- 
pation. 1 

All classes and conditions of life are liable thereto. It 
is found in both sexes, and at all ages. It is a matter of 
common observation that females are much more prone to 
this derangement than males, for the reason that besides 
the causes common to both sexes, there are a number of 
etiological factors, special to them, as ailments, acute or 
chronic, of their generative organs, relaxation of their 

1 Nouveau Dictionnaire de Medecine et de Chirurgie pratique, Jaccoud. 
Article "Constipation." 



DEFINITION; ETIOLOGY; CLASSIFICATION 45 

abdominal muscles, and the more stringent rules of 
modern society. 

It is not an uncommon condition in infants, and is fre- 
quently a source of more or less inconvenience to the aged. 

The causes that lead to this condition are many ; they 
can be well grouped under the following four heads : 

1. Pathological conditions, within or without the intes- 
tinal tract. 

2. Abnormalities of form, congenital or acquired, or 
dislocations of sections of the large bowel. 

3. Foreign bodies in some portion of the bowel. 

4. Defective performance of normal physiological 
function. 

Although various divisions of the subject have been 
already made, I believe that for clinical purposes, con- 
stipation, in whatever way produced, is best divided into 
two great groups : 

I. Acute Constipation. 
II. Chronic Constipation. 

By acute constipation I understand that form which, 
coming on suddenly, is but one of a group of symptoms 
of a special, well-defined, and acute pathological process ; 
where, in the treatment of the case, our attention is not 
specially directed to the relief of the constipation, even 
though we may resort to laxative medication ; where 
with the cure of the pathological process the constipation 
disappears. 

Chronic constipation embraces that form which is of 
slow and gradual development, and which does not 
present any acute morbid phenomena. 



CHAPTER VI 

ACUTE CONSTIPATION 

Acute constipation is produced in various ways : 

A. By direct obstruction of the lumen of the intestinal 
tube. This occurs, 

In Intussusception. 

In Volvulus (twisting or torsion) of the rectum or sig- 
moid flexure (the parts where it more commonly 
occurs). 

In Twisting or inversion of the caecum. 

In Strangulation by the edges of some orifice, natural or 
artificial, into which a section of the small intestine 
may have dropped. Such orifices are the foramen 
of Winslow, 1 perforations in the mesentery, meso- 
colon, great omentum, or other duplicatures of the 
peritoneum. 

In Strangulated hernia. 

In Obstruction by foreign bodies. 

The foreign bodies found in the intestinal tract can be divided, 
according to their derivation, into two groups : 

(a) Those introduced from without, 
(5) Those formed within the body. 

1 Rokitanski, Patholog. Anatomy. 
46 



ACUTE CONSTIPATION 47 

(a) The group (a) can be again divided, according to the 
mode of introduction, into two subgroups : 

1. Foreign bodies introduced by the mouth, 

2. Foreign bodies introduced by the rectum. 

1. The first of these subgroups is very well known to physi- 
cians, who are all more or less frequently consulted as regards 
thereto, especially in the cases of children, who seem to delight 
in the swallowing of extraneous matters. The bodies so intro- 
duced are varied in their nature : copper coins, pieces of silver, 
buttons, bones, pieces of glass, large pins, forks, and even open 
penknives have at one time or another found their way into 
the bowels. Though many of these bodies are of a formidable 
and rather dangerous character, it is nevertheless a fact, singu- 
lar as it may be, that in a great many instances, perhaps in the 
greater number, they have passed through the bowels without 
inflicting any injury. Though not properly pertaining to the 
subject under consideration, ' the following cases are recopied 
here for the great interest that attaches to them, and the 
important lessons they inculcate. 

Case 1. Sivallowing of open penknife. C. B. Hutchings, 
M.D. (Pacific Medical and Surgical Journal, 1886, XXIV. 35). 

On the afternoon of Thursday, 19th, a young man twenty 
years of age, while fooling with some boys and girls, swal- 
lowed an open penknife, handle first. On telephoning the 
neighboring doctor, he was ordered to drink nothing but milk, 
and to take a dose of castor oil. Fortunately, this advice was 
not followed, and he came immediately to the city, where he 
arrived at 7.30 p.m. The castor oil was not given, but instead 
he was instructed to eat a hearty meal of mush and buckwheat 
cakes, and on going to bed directed to lie on his right side to 
facilitate the passage of the knife into the duodenum. The 
next day he was directed to spend most of the da}^ on his right 
side with the hips elevated, and to eat freely of any food he 
desired, but particularly of buckwheat cakes. He claimed that 
he felt the passage of the knife through the ileo-caecal valve. 



48 CONSTIPATION IN ADULTS 

from the very considerable pain it caused. The bowels moved 
on Friday. On Saturday and Sunday the same food was pre- 
scribed, but on neither day did the bowels move. He claimed, 
however, that he felt the knife in the transverse colon, and on 
Monday in the sigmoid flexure, and late Monday he felt it 
sticking him in the neighborhood of the anus. The bowels 
did not move on Monday, but on Tuesday morning about 11 
o'clock there was an immense movement, which brought away 
the knife, point first. 1 

Case 2. Swallowing a plate with four teeth. M. L. Bates, 
M.D. (Transactions of the Medical Society of the State of New 
York, Vol. for 1886). 

C. E. W., aged thirty-eight, came to my house about 1 o'clock 
in the morning of October 9, 1885, and after arousing me from 
my slumbers, stated that about an hour before he was awakened 
from his sleep by a strangling sensation, accompanied by cough 
and choking. When sufficiently aroused from his sleep to know 
what was going on about him, he found that he had swallowed 
his teeth — artificial plate with four teeth attached ; he expe- 
rienced also pain and a sense of oppression in the chest in the 
median line, directly over the sternum, and felt that the foreign 
body had lodged at some point in the oesophagus. As he was 
obliged to travel about a mile to reach my office, when he 
arrived there the pain and oppression had ceased, and he then 
experienced an uneasy sensation in the stomach. On examina- 
tion I found that the foreign body had rjrobably passed into 
the stomach and that we must deal with the case from that 
standpoint. After obtaining a description of the plate, as to 
its size, etc., I informed the patient that it might possibly pass 
through the alimentary canal, but that if, in the course of six 
days, it should not pass, then the operation of gastrotomy 
should not be delayed. From the description of the foreign 
body given by the patient himself, I thought it impossible for 

1 A diet of potato mush, i.e. mashed potatoes, has been highly recom- 
mended for the purpose of enveloping, and thus rendering innocuous, sharp 
or pointed articles that may have been swallowed. 



ACUTE CONSTIPATION 49 

it to pass the pyloric orifice of the stomach. After giving 
him some directions he went away. On the morning of the 
sixth day he came to my office and informed me that the plate 
Avith all the teeth intact and encased in a pultaceous mass of 
fsecal matter passed his rectum that morning. He said that 
during the six days, no pain or even discomfort in any portion 
of his bowels was experienced. 

2. Foreign bodies are introduced into the rectum for diverse 
and many reasons, and are likewise very varied in their charac- 
ter : spools, pieces of wool, tumblers, bottles, candles, pieces of 
iron bar, etc. 

Case 3. Glass syringe broken in the rectum. N. M. Baskett, 
M.D. (St. Louis Courier of Medicine, 1891, IV. 76). 

Mrs. B, a widow, aged somewhere between fifty and sixty, 
is lying at the point of death with phthisis pulmonalis and will 
probably not live more than a few weeks. I was called upon 
by one of her relatives last week, who wished to consult me 
concerning the constipated condition of Mrs. B's bowels. She 
had had no passage for six or seven days. ... I wrote for 
glycerine to be administered in two-drachm doses with a small 
syringe by injection. She stated that she had a small glass 
syringe," and I told her she could use that. She administered 
the glycerine successfully. . . . The bowels began to act 
frequently and exhaustingly, and during the night it became 
necessary to use means to check them, and the lady concluded 
to try the injection of ten drops of laudanum by the rectum. 
In introducing the syringe the cylinder of the instrument was 
broken in an oblique manner, and two-thirds of it drawn into 
the rectum. The piston and the other portion of the syringe 
remained in the operator's hands. 

I was hurriedly sent for and the accident explained. I felt 
dubious concerning the matter, and I knew the danger of 
further fractures ensuing in any attempt to remove it. How- 
ever, it was no time for speculation. I greased my index 
finger, introduced it, and was so fortunate as to find the 
oblique fractured portion l} r ing in such a position that I could 



50 CONSTIPATION IN ADULTS 

slip the end of my index finger into the tube without cutting 
the finger. I then forced my thumb up until I could seize it 
between my thumb and index finger, and luckily removed it 
without fractures. This was indeed fortunate as the glass was 
scarcely thicker than a good quality of writing paper. 

Case 4. A piece of ivood driven into the rectum. W. C. 
Jones, M.D. (Occidental Medical Times, 1891, V. 375). 

On June 5, 1891, a Chinaman, sixty years of age, while 
mining in a ravine about two and a half miles from town, was 
approached by three men who demanded his money. They 
searched him and took all he had, — about three dollars in gold- 
dust, — but, thinking that by torture they could obtain more 
money, they sawed off six inches from the end of a hoe handle 
and forced it up the victim's rectum, wholly beyond the 
sphincter ani, and left him in this condition. This occurred 
at noon Friday. The following day, 10 a.m., he had walked 
to town and presented himself at my office. After some 
trouble, with a long pair of forceps, I grasped the foreign 
body, and as the not very carefully sawn end of the handle 
was downward, it required much force, and I presume pain, to 
deliver it through a strongly resisting sphincter. . . . The 
piece of wood was in the rectum twenty-two hours. 

Bodies so introduced, if they be of sufficient size to be 
retained in the rectum, will set up, by the pressure and irri- 
tation exercised upon the mucous membrane, an acute proctitis, 
an ulceration of the mucous membrane, which may go on to 
perforation, and the formation of fistulous openings, or, if the 
condition present be recognized in time and the ulceration 
healed, may result in stricture of the rectum. 

Again, bodies so introduced are, if they be not so large as 
to exert an inhibiting pressure upon the tissues of the rectum, 
transported upward by an antiperistalsis into various portions 
of the large bowel. Foreign bodies so introduced have been 
found in the sigmoid flexure, in the descending and in the 
transverse colon. 1 In their upward passage they are arrested 

1 Most convincing demonstration of an anti-peristalsis, which has been 
questioned by some. 



ACUTE CONSTIPATION 51 

at one point or another, and an acute obstruction of the bowels, 
an acute constipation, is set up. 1 

(&) The foreign bodies formed in the intestinal tract are 
themselves the result of a greater or lesser degree of consti- 
pation, and will be considered under another head. 

B. By pathological changes in one or more of the tissues 
of the intestinal tract, impairing their capacity for normal 
performance of their physiological function. This we 
find 

In the acute inflammation of the various sections of the 
large or small bowel. 

In the various forms of peritonitis. (It is the muscular 
coat of the intestine that is most frequently in- 
volved here ; it is infiltrated, tumefied ; and this, 
with the tying up of the intestinal tract by bands, 
the result of the inflammation, produces the con- 
stipation.) 

In some cases of typhoid fever. (Here also the muscular 
layer has been found tumefied, and the mucous 
membrane very much infiltrated, so much so as to 
project into the lumen of the canal.) 

C. By direct inhibition of peristaltic function through 
the nerve centres. This occurs 

In acute cerebral meningitis. 

In tubercular meningitis of acute form. 

In apoplexy. 

In acute mania. 

1 For further information upon this topic the reader is referred to Poulet, 
Corps Strangers en Chirurgie (an English translation extant), Paris, 1879. 
Gerard, Camille, Des Corps Strangers du Rectum, leurs migration dans 
l'intestin, etc., Paris, 1878. 



52 CONSTIPATION IN ADULTS 

In various acute diseases of the spinal cord and its en- 
velopes. 
In acute infectious diseases. 
In hysteria. 

Case 5. Adler reports a very interesting case : A young 
man, cet. seventeen, of German parentage, but educated in 
France ; neurotic tendency manifested since earliest child- 
hood ; neurotic taint in family. Claims to have suffered 
rather frequently in the last few }^ears from attacks of colic, 
with constipation, distension of the abdomen, and great pain. 
These attacks were accounted for sometimes by dietary indis- 
cretion, at other times no cause for their coming on could 
be discovered. Laxatives and belladonna were said to have 
relieved him in the course of a few days, provoking free dis- 
charge of gas and fgecal matter. The young man is organically 
sound, appears well nourished, has an excellent appetite, his 
digestion is good and his bowels are regular. All at once, 
without any known reason or cause therefor, he is seized with 
pain in his belly, with rumbling and gurgling therein, and dis- 
tention. The belly grows rapidly in size, and in twenty-four 
hours has reached enormous dimensions. The diaphragm is 
pushed high up, the abdominal walls are tense to bursting, and 
the whole abdomen is very sensitive to pressure. No fever, 
pulse quiet, and but little more frequent ; tongue clean ; vomit- 
ing rare, — only after certain articles of diet. Urine normal, 
but rich in phosphates. Urination rather difficult, probably in 
consequence of the great meteorism, so that the catheter must 
be resorted to several times. It is impossible to obtain an 
evacuation or to effect the discharge of even a little flatus. 
Laxatives administered are vomited ; those retained prove in- 
effective. As for rectal injections, but small quantities are 
tolerated, and these are again at once discharged, having had 
no effect. Digital examination of the rectum discloses a 
strongly dilated ampulla and so far drawn up that the internal 
sphincter cannot be reached with the finger ; otherwise nothing 
abnormal. This condition continues for five or six days. The 



ACUTE CONSTIPATION 53 

diverse remedies, both internal and external, prove ineffective. 
Atropine is not tolerated at all ; not even in minimal doses. 
Suddenly, after a few doses of the extract of Calabar bean and 
of mix vomica, faecal evacuations with abundant discharge of 
flatus follow, and the patient is well. He remained well for 
a few months, and then had another and much severer attack. 
The belly became distended, assumed in a few hours incredible 
dimensions. Respiration was very much embarrassed ; patient 
could lie only on his side, and then suffered greatly. This 
time the Calabar bean and nux vomica were without effect, 
and he remained in the state described for nearly a week. 
Then, upon a rectal injection of warm water to which a few 
drops of valerian had been added, fsecal and gaseous discharges 
followed, and the patient was well. The attacks recurred in 
the course of the following month. The patient returned to 
France, and was thus lost sight of. 1 

Adler believes that the acute constipation was the result of 
a spasmodic stricture suddenly developed ; there is, however, 
nothing in the history or in the examination to show that such 
was the case. 

If it is true that hysteria may be the cause of a spasmodic 
stricture, and that it may so act upon muscle is well demon- 
strated, it is likewise undoubted that it may act in a manner 
directly the opposite, i.e. inhibiting the normal nerve tonus 
and producing a paretic condition. 2 The acute cases, as the 
one described, are undoubtedly due to the latter mode of 
action, for reasons readily apparent. 

D. By absence of, or impairment of the quality of 
the bile. 

In the various acute diseases of the liver. 
In cholelithiasis during the passage of the gall stone 
through the common duct. 

1 New Yorker medicinische Monatschrift, 1892. 

2 See Rosenthal, Diseas. of the Nerv. Syst. Charcot, Lee. sur les Mai ad. 
du Syst. Nerv. Gowers, Dis. of the Brain and Spin. Cord. 



54 CONSTIPATION IN ADULTS 

E. By inhibition of the aid of the diaphragm and ab- 
dominal muscles. 

In acute diseases of the lungs and pleura. 

In rheumatic diseases of the abdominal muscles. 

In hyperesthesia of the abdominal parietes. 

In paralysis of the diaphragm and abdominal muscles. 

In acute diseases of the female genital tract. 

F. Refiexly. 

In the inflammations of retained testicle. 

In some of the acute diseases of the female genital tract. 

In acute diseases of the bladder and prostate. 

G. By a combination of these various ways. 

In acute inflammations of the stomach. 
In attacks of gout. 

In all the various forms of constipation here considered, 
with the exception of groups "A" and " C," there are 
other circumstances, additional to the principal ones 
already named, that tend to produce the constipation. 
These are: The abstemious diet to which the patient 
confines himself already in the prodromic stage by reason 
of the loss of appetite ; the sudden change in the char- 
acter of the food, which in the invalid state consists 
altogether of bland, non-irritating articles ; the small 
quantity of food taken ; the recumbent position ; the want 
of the usual exercise ; frequently, also, the medication. 

The pathology of the various morbid states referred 
to in this category as well as the treatment thereof are 
found in extenso in the numerous text-books, and the 
more pretentious works both on medicine and surgery, 
and in special treatises. 



ACUTE CONSTIPATION 55 

This category of constipation, as has already been 
indicated, does not concern ns. It is not the constipation 
that requires our attention here, but the pathological 
process of which it is but one of the symptoms. 

However, there are a few points relating to group 
a A " to which I would briefly call attention : 

1. The Bauhinian valve can be passed by fluids 
injected with some force into the rectum. 1 

2. Injections of large quantities of water with the 
powerful pump described in my paper on Intestinal 
Obstruction 2 are of the greatest value both as to the 
restoration of the normal status where such is possible, 
as in the various forms of intussusception and of volvu- 
lus, and as to the clear and distinct indication for opera- 
tive interference where such restoration to the normal 
does not at once result. 3 The long delay which greatly 
diminishes the chances of the operative procedure, and 
is therefore fatal to the patient, is done away with. 

3. The value of the alternate use at brief intervals of 
hot and cold water, or hot and cooler water, according 
to the indications. I believe I can claim for myself 
priority in the use of hot water for rectal injections in 
the treatment of the conditions referred to, and in the 
use of hot water of a temperature of 106° F., for rectal 
injections, as, previous to the publication of my article, 
no such injections were described, at least not to my 
knowledge. 

1 See my article "Intestinal Obstruction," America?! Journal of the Medi- 
cal Sciences, January, 1886. Senn, Experimental Surgery, Chicago, 1889, 
p. 479. 2 ibid. 

8 See the casuistry in the article "Intestinal Obstruction," American 
Journal of the Medical Sciences, loc. cit. 



CHAPTER VII 

CHRONIC CONSTIPATION 

Considering the varied nature of the etiological factors 
that give rise to it, chronic constipation is best studied 
subdivided, according to the mode of its production, into 
the following four groups : 

A. Chronic constipation produced by well-defined mor- 
bid processes. 

B. Chronic constipation by obstruction from foreign 
bodies. 

C. Chronic constipation produced by congenital mal- 
formation of a section of the large bowel, or by defective 
development of the intestinal tract, or by dislocation of 
any part thereof. 

D. Chronic constipation from impairment of physio- 
logical functioning alone. 

Section I. Chronic Constipation from Disease 

The morbid processes which cause chronic constipation 
do so in various ways : 

1. By obstructing the lumen of the tube : 

Cicatricial narrowing of any portion of the intestinal 
tract (as the result of the healing of an ulcer, or 
after dysentery). 

56 



CHRONIC CONSTIPATION 57 

Constriction of a section of the intestinal tract by bands 

(after peritoneal inflammation). 
Constriction of the caecum and of the jejunum (after 

typhlitis or perityphlitis). 
Cancerous disease of the large bowel (the rectum is the 

part most frequently affected). 
Tumors in the abdominal cavity pressing upon the bowel 

and occluding it. 1 
Massive exudations of blood (hematocele), or of serum, 

into the cellular tissue of the pelvis. 
Obstruction of the rectum by a retroverted uterus. 
Tumors within the rectum. 
Folds of mucous membrane. 

Kesley, 2 in a clinical lecture, refers to a patient long afflicted 
with constipation, in whom, .on downward pressure at stool, 
large and abundant folds of mucous membrane came down 
which completely cut off the orificium ani from the rest of 
the rectum. As he says, it is " a prolapse which does not 
protrude." 

2. By impairment of the secretions poured into the in- 
testines : 

In chronic diseases of the liver, when the secretion of the 
bile is deficient, or perhaps almost altogether wanting ; 
or when the bile secreted is not of normal character. 

In diseases of the pancreas. Constipation is rather fre- 
quent in the diseases of this organ, and adds greatly 
to the severity of the suffering. 3 

1 Rosenblatt (Centralblatt f. Chirurgie, 1882, No. 29, p. 64) reports a case 
of complete intestinal occlusion produced by a cyst of the pancreas. 

2 New York Medical Journal, May 16, 1896. 

3 Hinrichs, "Beitrag zur Lehre v. d. Erkrankungen des Pancreas." Inaug. 
Dissertation, Berlin, May, 1889. 



58 CONSTIPATION IN ADULTS 

3. By inhibition of peristalsis through the nerve cen- 
tres : 

In chronic diseases of the brain. 

In chronic affections of the spinal cord and its envelopes. 
In chronic forms of insanity. 

In saturnine intoxication (lead paralysis ; saturnine en- 
cephalopathy). 

In tabes dorsalis (locomotor ataxia) most obstinate 
constipation is frequently observed. Henrot reports an 
instance in which a constipation so obstinate supervened 
that the original nervous affection was lost sight of, and 
an intestinal obstruction presumed. An autopsy showed 
the tube free from all lesion or obstruction, and revealed 
marked atrophy of the cord, both of the anterior and 
posterior spinal roots. 1 

In the paralysis after diphtheria. 

4. By chronic venous congestion of the intestinal circu- 
lation : 

In organic disease of the heart. 

In some chronic pulmonary affections, as asthma, em- 
physema, etc. 

5. By voluntary abstention from stool on account of the 
pain it causes by reason of a diseased condition of the 
rectum : 

In haemorrhoids. 

In ulcers of the rectum. 

In fissure of the anus. 

1 Henrot, Des Pseudo-Etranglements, Paris, 1865. 



CHRONIC CONSTIPATION 59 

In chronic inflammation of the rectum (chronic proctitis). 
In abnormal irritability of the rectum, — "irritable rectum, 
hysterical rectum" 

6. By changes in the mucous membrane which impair 
its irritability, and if they involve a more, or less exten- 
sive portion of it, render it incapable of performing its 
physiological function in the process of digestion : 

In saturnine intoxication. 1 

In chronic catarrh of the small intestines. 2 

In membranous enteritis. 

In the two latter diseases there are several other fac- 
tors that can be regarded as assisting in the development 
of the constipation and its persistence, viz., change of 
diet (as most patients so afflicted confine themselves to 
bland, unirritating food, of, a concentrated nature, having 
but little residue), restriction in quantity, etc. 

In atrophy of a section or sections of the intestinal mucous 
membrane (after catarrhs)." 

7. By atony of the intestinal muscles produced by mor- 
bid conditions of the stomach or of the boivels : 

In atony of the stomach. 

In some of the cases coming under my observation, I was 
inclined to believe that the atony of the stomach was secondary 
to the atony of the intestines. 

In dilatation of the stomach. 

1 Where the lead has as yet acted locally only. 

2 It is almost an aphorism that catarrhal disease of the small intestines is 
attended by constipation, whilst diarrhoea is a prominent feature of catarrh 
of the large bowel. 

3 Nothnagel, Beitrage z. Physiol, u. Pathol, d. Pannes. 



60 CONSTIPATION IN ADULTS 

The solids and fluids ingested are retained for an undue 
length of time in the stomach, and pass out but very 
slowly and in very small quantities. In fact, stagnation 
is its characteristic feature. No doubt that the intestinal 
muscles, also, are in an atonic condition. It is not un- 
likely that some of the intestinal structures, the mucous 
membrane most probably, are in a morbid state. 

Gastric and intestinal dyspepsia (so-called) are said to cause 
constipation. I have not considered them among the etio- 
logical factors for the reason that I hold, without going here 
into the question what is dyspepsia, that constipation is not at 
all one of their symptoms, and when it is present, it is not the 
result of the morbid state of the stomach or bowels. It is due 
to the fact that these patients reduce their diet greatly both in 
quantity and quality, confining themselves, almost exclusively, 
to bland, concentrated material. Not infrequently the dyspep- 
sia is the result of the constipation. 

As a sequence of prolonged catarrh of the large bowel. 

Section II. Chronic Constipation from Foreign 

Bodies 

The foreign bodies that give rise to chronic constipa- 
tion are such as are of gradual growth, whether the 
materials of which they are formed are excretions or 
abnormal formations of the bodv, or are introduced from 
without. 

Case 6. Intestinal obstruction by a mass of hair. Dr. Tefft. 

A young girl, ait. seventeen, of sickly aspect, has long 
had the habit of swallowing all sorts of things. About her 
fifteenth year she menstruated at two periods, but never after 
that. She sickened ; complained of cardialgia and of head- 



CHRONIC CONSTIPATION 61 

ache ; vomiting and diarrhoea 1 supervened ; she emaciated 
markedly and lost greatly in strength. The vomiting was 
so incessant that all nutrition was inhibited. Gradually the 
belly became painful to the touch , the presence of a tumor, 
not depressible, indolent, hard, cylindrical, without fluctua- 
tion and occupying all the region between the anterior border 
of the ninth rib and the anterior superior spinous process 
of the ileum, was noted. On percussion, the region occu- 
pied by the tumor gave a dull, flat sound, whilst the other 
portions of the abdomen resounded rather sonorously. The 
vomiting soon became faecal, the constipation absolute, and 
death soon closed the scene. At the autopsy it was found that 
the tumor was formed by the caecum and ascending colon, 
which were filled with a foreign voluminous mass. This mass, 
which tapered off: at its upper extremity, where it penetrated 
into the ileum through the ileo-csecal orifice, was fifteen centi- 
meters long and composed at its base of a mass of hair mixed 
with excrementitious material ; the upper portion was a mass 
of cotton, and that part of it which penetrated into the ileum 
consisted of threads of flax and pieces of packthread. 2 

Case 7. Voluminous intestinal concretions. Pupier. Z. 

M. Pupier presented to the Medical Society of Lyons a cal- 
culus still greater than the one presented by M. Andry (which 
weighed forty grammes), weighing fifty-eight grammes, com- 
posed of almost pure cholesterine, and discharged only after a 
labor very much like that of an accouchement. The patient, 
a colleague, had never suffered from frank hepatic colic, though 
he frequently had pain on going to stool (before the evacua- 
tion), or felt some embarrassment about the level of the caecum; 
the stools were colorless. By means of purgatives the calculus 
was dislodged, but not until after an anal drama, to use the 
picturesque phrase of the patient, which lasted over forty-eight 
hours. According to the victim of this accident, it is probable 

1 This form of diarrhoea will be referred to again further on. 

2 Schmidt's Jahrbiicher, 135, p. 74. Also Poulet, Corps Strangers en 
Chiruro-ie. 



62 CONSTIPATION IN ADULTS 

that the powder of cholesterine accumulated for a long time in 
the caecum and there formed a mass. 1 

It has already been said, and it is, I think, rather 
clearly demonstrated by the above histories, that such 
accumulations, especially as the one in case seven, are 
really themselves the result of a previously existing con- 
stipation or insufficient activity of the bowels ; for with 
a normal activity of the intestinal tract and a normal 
cleansing thereof, no such accumulation could occur ; 
certainly not very easily. Undoubtedly, when the mass 
has attained a sufficient size, it tends to aggravate the 
already existing constipation. 

Section III. A. Malformations of the Intestines 

The malformations of the intestines are most varied 
in their nature, and may involve any and all parts 
thereof. Greig 2 describes a case in which the major part 
of the small intestines was entirely wanting. Atkins 3 
reports the history of an infant in whom the large bowel 
was found in a rudimentary state, and seemed, at first 
glance, impervious. On removal, however, of the whole 
alimentary tract, it was discovered that by the exercise 
of considerable pressure, a little meconium could be 
squeezed out. Other and more frequently occurring ab- 
normalities will be referred to more in detail in the 
section treating of the constipation of infants. All these 
forms produce a constipation that belongs in the cate- 
gory of the acute, and are either altogether incompatible 

1 Lyon Medical, 1887, LIV. 546. 

2 Canadian Practitioner, February 16, 1893. Sajou's Annual, 1893, Vol. V. 

3 Lancet London. 1885. Vol. II. 



CHRONIC CONSTIPATION 63 

with life, or require prompt surgical interference for their 
relief. 

The malformations that are compatible with a more 
or less prolonged existence and that give rise to a state 
of chronic constipation, to a retardation of faecal dis- 
charges, are, so far as hitherto reported : 

1. Abnormally developed colon. 

2. Undue length or size of sigmoid flexure. 

3. Diverticula of the large bowel. 

The true diverticulum of the small intestine (diverticulum 
ilei, MeckeVs diverticulum^), if it prove an obstacle to defecation, 
does so by constricting or strangulating a segment of the intes- 
tine, and the constipation thus resulting is consequently of the 
acute variety. 1 

The false diverticula of the small intestines are, in so far as 
their influence on the movements of the bowels is concerned. 
harmless. 2 

4. Diaphragms in the large bowel. 

From what has already been said in the chapter on 
" Intestinal Peristalsis," it can be at once understood how 
the conditions just named should give rise to a state of 
chronic constipation. For better illustration, a few of the 
cases coining under the various heads have been excerpted. 

1. Abnormally Developed Colon. 

Case 8. Chicago Medical Journal, 1867. Dr. William 
Lewitt. 

A young man, cet. twenty-one, was constipated ; had not had 
an evacuation for three weeks. The patient was found suffering 

1 Osier, Annals of Anat. a. Surg., Brooklyn, 1881. Treves, Intestinal 
Obstruction. 

2 Treves, loc. cit. 



64 CONSTIPATION IN ADULTS 

intense pain in the abdomen, with frequent desire to expel flatus 
from the rectum, which he could accomplish only by standing 
upon his head and hands in a perpendicular position. The abdo- 
men was enormously distended, and so tense that it was impossi- 
ble to feel the outlines of any abdominal organ. He had had a 
similar attack when he was about twelve years of age, and has 
ever since then been suffering from torpor of the bowels, hav- 
ing an evacuation only once in eight or ten days. Upon exami- 
nation per rectum, there was found what appeared to be an 
enormous tumor filling up the entire pelvic cavity. The 
rectum appeared to be normal. . . . About a week after the 
first visit, the patient was seized one day with excruciating 
pain in the abdomen, and, after a few hours, expired. 

Post mortem examination, six hours after death. The peri- 
toneal cavity was enormously distended with gas, and a large 
quantity of faecal matter of battery consistence was extravasated 
into it, showing that perforation had taken place, and was the 
immediate cause of death. Perforation had taken place at 
several points in the colon. The ascending and descending 
colon (for there was no transverse) appeared like two immense 
cylinders, lying side by side, and extending from the epigas- 
trium to the pelvis, and filled with soft faecal matter, and each 
was about five and one-half inches in diameter. The caput 
coli was not much enlarged ; the transverse colon was entirely 
obliterated, and the two cylinders of the ascending and descend- 
ing colon were folded upon themselves, filling up the entire 
abdominal cavity. The sigmoid flexure was about the same 
diameter, and what was supposed to be the tumor filling up the 
pelvic cavity was the sigmoid flexure enormously distended with 
faecal matter, and folded down upon itself, giving it the firm 
and rounded shape of a tumor that was supposed to exist, and 
pressed so firmly down upon the upper portion of the rectum 
as to prevent all passage of faecal matter into it. The colon was 
very much thickened, and completely filled with faecal matter of 
a battery consistence, containing over a large wooden pailful, 
besides what had extravasated through the perforation into the 
peritoneal cavity. 



CHRONIC CONSTIPATION 65 

The reason for his adopting that peculiar and unnatural posi- 
tion to enable him to expel the flatus from his bowels was, that 
by that position the weight of the distended sigmoid flexure 
was taken off the upper portion of the rectum, and allowed a 
small quantity of flatus to escape, which afforded him some 
relief. 

I have no doubt that the change of position and the enlarge- 
ment of the colon were congenital. The youth of the patient, 
the early age at which his trouble began, seem to clearly demon- 
strate this, and, although we have no history of constipation to 
his twelfth year, it is more from ignorance or inadvertence. 

Case 9. Enormous congenital development of the colon. Dr. 
Formad (University Medical Magazine, June, 1892). 

I. W.,cet. twenty-nine years, white, single; was found dead 
in the water-closet of the society to which he belonged. . . . 
His mother tells that up to the age of one and one-half years, 
the subject under consideration was a normal infant, with 
the exception of a rather large abdomen, frequent irregularity 
of the bowels, and attacks of constipation ; but no other de- 
formity of the body had been noticed up to that time. Sub- 
sequently, and especially noticeable at the age of two years, 
the abdomen began to swell and the disturbance in defecation 
to be more marked, so that constipation would last from two to 
four days as a rule. His appearance was said to have been that 
of a marasmic child, lean and emaciated, and until five years of 
age he was unable to rise without assistance. Subsequently the 
bodily development was progressive, although he was rather 
spare. At the age of twelve years he was able to go to school, 
and, although the history of his intellectual success as a school- 
boy is uncertain, he appeared to have had the normal intelligence 
of lads of his age. At the age of sixteen, he earned his living 
at a foundry for eighteen months at continuous work. Subse- 
quently he worked for several years as a laborer at an oil 
refinery, and while his work was uninterrupted during this 
period, his parents say that he was subject to habitual constipa- 
tion, said to last as long as a whole month at a time, although 



QQ CONSTIPATION IN ADULTS 

no correct clinical data covering this period of his life could be 
obtained. Yet it was obvious that his abdomen continued to 
grow in size. At this period of his life, while not feeling dis- 
tressed by any painful ailment, he is said to have visited the 
dispensaries of various hospitals of this city. At twenty years 
of age his abdomen had reached very large dimensions, and the 
figure of his body became so peculiar that the manager of the 
Ninth and Arch Streets Museum saw fit to put him on exhibi- 
tion as a freak, and for eight or ten years he was known as the 
" Windbag or balloon man." . . . The whole history of his 
life and habits does not present anything peculiar, except that 
he had an enormous appetite, and was generally a good feeder. 
He was known to relish a few heavy meals a day. He was 
occasionally of intemperate habits. 

Autopsy twenty-four hours after death. 



Abdomen. — No excess of the peritoneal fluid, although the 
surfaces of the peritoneum had an unusual degree of moisture. 
The color of the surfaces was normal, no evidence of any 
hyperemia or inflammatory conditions in any part. A most 
striking appearance was presented by the colon. It was dis- 
tended by faecal contents and gas, and, although occupying a 
normal direction in the abdomen, it was of huge dimensions, 
and occupied a large portion of the thoracic region of the body. 
By a rough estimate it had the appearance of being at least 
ten times wider than normal, the exact measurements being 
as follows: total length of colon, 2.52 metres (about 8 feet 
4 inches). The rest of the figures relate to the circumference 
of the bowels. Ctficum, 26 cm. (10 inches) ; colon, ascending 
part, 37 cm. (15 inches); colon, transverse part, gradually 
increasing from 38 cm. to 76 cm. (15 inches to 30 inches); 
colon, descending part, 60 to 62 cm. (24 to 25 inches); sig- 
moid flexure, 62 to 69 cm. (25 to 27 inches). 

The mesocolon was abnormally large and thick, which, how- 
ever, was perfectly consistent with the enormous hypertrophy 
of the colon. 




Human colon, congenital giant growth and coprostasis. The more distended end 
is the sigmoid flexure. The narrow part taking exit from it represents the greater 
part of the rectum, which was normal. The narrow distal end of the preparation 
represents the head of the colon with the string attached to a fragment of the small 
intestine. The arched part of the specimen represents the transverse portion of the 
colon. — The figure within represents a normal human colon photographed simulta- 
neously for comparison of dimensions. Dried preparations. 

07 



68 CONSTIPATION IN ADULTS 

The whole of the colon thus presented a gradual increase in 
size or width from the caecum to the sigmoid flexure, the great- 
est increase in width being in the transverse portion. 



The contents of the colon was represented by two pailfuls of 
fseces, which weighed forty pounds. The physical character of 
the fasces appeared to be normal, appearing as a semi-fluid, dark- 
brown mass, with, perhaps, a greenish tinge ; microscopically 
and chemically nothing abnormal was discovered. 

The rectum was perfectly normal in dimensions ; its muscu- 
lar coats were quite thick, and it presented a striking transition 
from the extreme dilatation of the sigmoid flexure and rest of the 
colon above, to that of contraction, although no abnormal ana- 
tomical appearance of contraction that could have led to any 
obstruction could be discovered either in the rectum or anus. 

This remarkable excess in size was, however, limited to the 
large intestine, the small intestines as well as the rest of the 
alimentary canal being of normal dimensions. 

2. Undue Size of Sigmoid Flexure. 

Case 10. Enormous dilatation of the sigmoid flexure. Dr. 
Harrington (Chicago Medical Journal and Examiner). 1 

I was called January 31 at 10 a.m. to see J. B. Farmer, 
aged fifty-one years, suffering from intense pain. He had been 
subject to bilious colic for nearly ten years, during which he 
vomited frequently and severely and suffered from severe pain 
in the bowels. He had been troubled with constipation, espe- 
cially preceding these attacks. He had also not felt well for 
nearly a week, and the day previous began having severe par- 
oxysmal pains in the bowels, accompanied by nausea and vom- 
iting, which continued during the night, and were still present. 
The skin was about normal ; tongue dry, white fur in the 
centre ; pulse 70, soft ; temperature normal ; appetite lost ; 

* Vol. XXXVI., 1878, p. 400. 



CHRONIC CONSTIPATION 69 

bowels constipated ; abdomen slightly tympanitic, and some- 
what tender ; no tnmor could be felt ; the material ejected by 
vomiting consisted of bile, mucus, and fluid taken into the 
stomach. 

The patient frequently tried to eject gas from the stomach 
by belching. The swelling of the abdomen kept increasing 
until midnight, becoming finally enormous, and causing great 
distress. ... I passed a No. 10 catheter into the stomach, 
when quite a quantity of gas escaped. The abdomen was so 
tense that it seemed as if the gut must rupture. A distinct 
ridge revealed (as I thought) the outline of the distended 
colon. ... I kept him quiet with hypodermic injections until 
Dr. S. M. Hamilton, of Monmouth, who had been called in 
consultation, agreed with me as to the necessity of tapping, and 
very skilfully operated, perforating, as we supposed, the ascend- 
ing colon, and giving vent to a very large quantity of offensive 
gas. This gave great relief. ... At 11 o'clock I tapped the 
bowels again about one-half an inch above the first puncture, 
permitting the escape of a still larger quantity of gas. . . . 
He rested quietly until 3.30 o'clock a.m., when he began to 
sink, and died at half -past four. 

Autopsy ten hours after death. Rigor mortis marked. On 
opening the abdominal cavity, I cut down upon what proved to 
be an immense sac-like dilatation of the sigmoid flexure which 
entirely covered the anterior surface of the bowels, and which 
we had punctured on the right side, instead of the ascending 
colon ; it extended as high as the cruciform cartilage, and was 
perfectly black from congestion. Further examination revealed 
extensive enteritis and general peritonitis. The sac was empty, 
its walls thick and muscular, and it would hold at least a gallon. 
No faecal accumulation in any part of the bowels. No apparent 
contraction below the sac. No morbid deposit in the walls of 
the rectum. The liver and spleen were congested and some- 
what softened ; other organs healthy. 



■ 



70 CONSTIPATION IN ADULTS 

Case 11. Abnormal congenital development of the sigmoid 
flexure. Intestinal occlusion. Dr. Eisenhart (Centralblatt f. 
Innere Medicin, No. 49, 1894). 

Patient female, cet. thirty-five years ; has always suffered 
from constipation and therefore resorted to various purgatives, 
so that she had an evacuation once in three or four days. In 
the year before, in consequence of a puerperium, she suffered 
a strong psychic disturbance and was placed in an institution 
for treatment. At this time a condition developed very much 
like the present : obstinate constipation, great distension and 
tenderness of the abdomen, nausea without vomiting, and 
marked disturbance of the general health. After many things 
had been tried, a drastic purge was given per os on the tenth 
day and an evacuation resulted, whereupon the patient rapidly 
recovered. Torpidity of the intestines as before. 

Two days ago she was seized with pain in her belly, which 
day by day increased in severity and duration. At the same 
time a rapidly growing distension of the belly manifested itself 
and in consequence thereof there was marked disturbance of the 
general health, loss of appetite, and loss of sleep. No evacua- 
tion of the bowels in two days. 

I saw the patient for the first time on October 5, 1893. She 
lay in bed moaning and complaining ; face anxious and pain- 
ful in expression, but fresh in appearance. Axillary tempera- 
ture 37° C. Pulse 78. Abdomen greatly distended, like that of 
a gravid woman in the last weeks ; greatest circumference, 
103 cm. ; distance from symphysis to navel, 16 cm. ; from 
symphysis to xiphoid cartilage, 41 cm. Beneath the thin but 
otherwise unchanged abdominal walls, the greatly distended 
intestines, in very slow but uninterrupted peristalsis, are 
plainly visible ; from up on the right side diagonally down- 
wards to the left there stretches a segment of bowel which 
from its size (thickness of a man's arm) and its configuration 
(constrictions) appeared to be the transverse colon. The 
abdomen is painful to the touch, for the reason that peristaltic 
movements are thereby provoked. Vaginal examination, in so 
far as a result can be obtained without bimanual examination, 



CHRONIC CONSTIPATION 71 

which was impossible, disclosed a normal condition ; retroflexion 
of the uterus, which, as is well known, may cause occlusion of 
the bowel even in the non-gravid female, can be excluded. The 
rectum, so far as the finger can reach, free. No hernias. 



The various means and measures resorted to for the relief 
of the occlusion proving fruitless, Professor Dr. Bauer was 
called in consultation ; surgical interference advised, and the 
patient transferred to the surgical clinic. October 13, a 
cceliotomy was made. The extremely distended segment of 
bowel covered the whole field of operation, and rendered a 
recognition of localities rather difficult. An incision was there- 
fore made into it, and although gas and a considerable amount 
of semi-solid fsecal matter were evacuated, but little diminution 
in size resulted. (The incision was immediately closed with 
sutures.) Nevertheless, it was now possible to recognize the 
obstructions ; in the region of the sigmoid flexure the bowel 
was bent upon itself at a sharp angle, and several loops of the 
small intestines had passed through a slit in the mesentery and 
become thereby constricted. The obstructions were removed 
and the wound closed. The expected result did not follow. 
A few hours after the operation the previous condition of 
things again prevailed, and before the abdomen could be 
opened the second time the woman died, on the afternoon of 
the day of operation. 

Post-mortem Examination. — The so enormously developed 
segment of bowel was not the transverse colon, as had been 
supposed, but the sigmoid flexure. It was about 60 cm. long, 
and lay in the form of an arc from the left side over and up to 
the right, and down on to the left, passing into the normal 
rectum. The lower segment of the flexure near its junction 
with the rectum, having become overfilled, was dragged down- 
ward, bent at a sharp angle, the rectum closed off, and the 
occlusion thus produced. The subsequent peristalsis drove the 
contenta more and more into the diverticular-like space, and 
by the pressure thus made the upper portion of the rectum was 



72 CONSTIPATION IN ADULTS 

being constantly drawn downward, and was thns more and 
more shut off. 

Width of flexure laid open, 33 cm. (normal width, according 
to Cruveilhier, 14 cm.). 

3. Diverticula. 

Case 12. Congenital diverticulum of the sigmoid flexure. 
Drs. Fiitterer u. Middendorpf (Virchow's Archiv, Bd. 106). 

Chr. H., fourteen years old; admitted to Julius Hospital, 
February 3, 1886. The father of the patient is alive and in 
good health, but the left side of his face, especially the left half 
of the lower jaw, is less developed than the right side. . . . 
Already at his birth, which was a perfectly normal one, the 
patient is said to have had an unusually large belly, larger 
than other children. Its circumference increased in the fol- 
lowing }^ears slowly but steadily ; he, however, suffered but 
little inconvenience therefrom. He went to school and was a 
good scholar. About a year ago there was such a marked 
increase in the circumference of the belly, that he could not 
attend school regularly, and if he ran a little he lost his breath. 
No palpitation, patient claims. . . . He had about three stools 
daily. 

Status Prcesens. — The great distension of the abdomen 
has produced a distension of the lower portion of the thorax. 
The skin of the abdomen is pale, drawn very tense, not oedema- 
tous ; on the anterior surface, corresponding, about, to the 
course of the vena epigastrica inferior, the veins are dilated 
and show through with a bluish tint ; a similar network of 
dilated veins is seen on the outer side of the abdomen, about 
the region of the axillary lines. The abdomen is symmetrically 
distended, barrel-shaped ; no tuberosities or protuberances 
noticeable anywhere. Eight centimetres above the navel and 
more particularly upon the left side, there are indications of 
a slight, horizontal, transversely running constriction. The 
navel is pushed out on a level with the rest of the abdominal 
surface. No especial changes to be seen on deep respiration 
or on change of position. 



CHRONIC CONSTIPATION 73 

The circumference of the thorax, on a level with the mam- 
millae, 75^ cm.; circumference of the abdomen on a line with 
the navel, 91 cm. ; greatest circumference at a point 8 to 10 cm. 
above that of the preceding measurement, 100 cm.; distance 
from navel to xiphoid cartilage, 28 cm. ; from the navel to the 
symphysis, 21 cm. ; from the navel to the anterior superior 
spines of the ileum, right and left, 26 cm. 

T^" /f£ 7$ 7$% 7fc Vff Tfs 3K 1 3fs 7f7 TfC 

Percussion of the abdomen with the patient in dorsal decu- 
bitus gives everywhere a tympanitic sound ; about 3 cm. above 
the symphysis and in the direction of the musculus quadratus 
lumborum, right and left, this becomes a dull tympanitic one ; 
absolute dullness nowhere. The patient sitting upright, absolute 
dullness or flatness cannot be made out anywhere ; the bounda- 
ries are very nearly the same in the sitting or lying position. 
. . . Auscultation of the abdomen, negative. The abdominal 
walls are very tense ; more solid masses that could lead to the 
assumption of a knotty tumor are nowhere to be palpated. On 
striking the abdomen on one side, the wave is distinctly per- 
ceived on the opposite side and in the middle about the navel ; 
the same result with the patient sitting upright or lying on 
either side. The consistency of the liver, soft, elastic. No 
swelling of the inguinal glands ; no oedema of the lower 
extremities. 

The finger introduced into the rectum readily sweeps the 
promontory ; nothing abnormal about the pelvic organs ; strik- 
ing the anterior abdominal parietes, the point of the linger 
perceives the wave, though rather indistinctly, on the anterior 
rectal wall. 

Urine scant, acid, opaque ; contains albumen, but no sugar. 
Sediment consisting of amorphous urate of soda and crystals 
of uric acid. February 4, one litre of warm water is injected 
into the rectum ; the point of the stomach tube (English), 
which was readily introduced to the height of 20 cm., could be 
felt 8 to 10 cm. to the left of the navel, and on a level with it. 
Nothing special found on percussion after the injection. Ap- 
petite moderate ; fever none. 



74 CONSTIPATION IN ADULTS 

In the following days two semi-solid, pap-like stools were 
obtained daily by means of mild cathartics and daily injections, 
the point of the rectal tube being easily pushed up to the left 
costal border, about 30 cm. from the anal orifice. The faeces 
had always the same grayish-brown, dark color ; odor not par- 
ticularly offensive. By reason of the abundant dejections, the 
circumference of the abdomen decreased, and by February 8 
this diminution reached 5 cm. ; the belly became softer, but no 
difference on percussion could be noted; not even after the 
injection of two litres of water. Urine, daily quantity, 700 to 
800 c. cm. Albumen disappeared after the third day of his 
sojourn in the hospital ; the sediment disappeared likewise. 

On February 6, when the abdominal walls had become 
very much less tense, and the circumference of the belly had 
decreased 3 cm., there was very plainly felt, on rectal palpa- 
tion, above the promontor} r , a soft elastic swelling with smooth 
surface, and not delimitable upwards by palpation. Striking 
the belly, the concussion of a slight wave could now be clearly 
felt in the rectum. Temperature within normal limits. 

February 8. An injection of one litre of lukewarm water 
was made this morning, and was followed by copious stools. 
Twenty drops of tincture opii are then given, and whilst the 
patient is narcotized, a trocar of moderate calibre is pushed 
into the left lumbar region, where a dull tympanitic sound had 
responded to percussion, and a grayish-dark, fluid, faecal-like, 
odorless mass is evacuated, in which, upon microscopic exami- 
nation, undigested muscle fibres are found. 

The rectal tube was now introduced to the height of 25 cm., 
and the point could be plainly seen and distinctly felt from the 
exterior. An incision 4 cm. long was made in the linea alba, 
through the attenuated abdominal parietes, about 5 cm. below 
the navel. After dividing the peritoneum, there appeared in 
the line of the incision numerous dark, bluish red, turgescent, 
easily compressible veins, 2 to 3 cm. in calibre, which ran in all 
directions upon the grayish white and very tense wall of a cyst. 
Intestines were not to be seen. No ascitic fluid. There being 
great danger of haemorrhage from the enormously dilated veins, 



CHRONIC CONSTIPATION 75 

the operation was discontinued, the wound closed with three 
rows of sutures and an antiseptic dressing put on. . . . The 
patient never complained of pain ; it was only the meteorism 
that annoyed him, and the stomach tube had to be introduced 
about four times a day to relieve him ; frequently even this did 
not avail. 



During his stay in the hospital, the patient took but very 
little solid food. He lived almost exclusively upon eggs and 
Tokay wine. The amount of faeces was never in proportion 
to the amount of food taken, but always four to five times, 
frequently more, in excess. 

Post-mortem Examination. — Emaciated male cadaver ; abdo- 
men very much distended. On laying open the abdominal 
cavity, a sac is cut into, whose tensely drawn anterior wall is 
in close apposition to the very much thinned abdominal walls, 
and large quantities of very fetid gas are set free. It is more 
than half filled with fluid fasces (eight litres), and occupies the 
whole abdominal cavity. The diaphragm is pushed far up and 
stands to the right, in the mammillary line, at the fourth rib ; 
to the left, at the lower border of the second rib. 

The stomach lies in the left concavity of the diaphragm and 
its greater curvature runs in the parasternal line, about four 
fingers' breadth above the costal arch ; almost the whole bowel 
lies up here and behind it, and maintains this position even 
after the above-mentioned sac has been evacuated. Both kid- 
neys are in the normal position, and show no changes. The 
liver lies in the right concavity of the diaphragm, and is like- 
wise pushed up ; its lower border, in the mammillary line, four 
fingers' breadth above the costal arch. 

In the stomach there are found, in small quantity, thin, 
bright-yellow, faecal masses ; the mucous membrane is un- 
changed. The mucous membrane of the small intestines is 
discolored a slaty gray ; that of the large bowel, which con- 
tained hard faecal masses, is similarly discolored. 

The colon descendens, which is markedly contracted at its 



76 CONSTIPATION IN ADULTS 

lower portion, opens into the enormously dilated sigmoid flex- 
ure. . . . The colon descendens is united to the upper and 
anterior portion of the sac by a mesentery which is 8 cm. at its 
longest point ; it has a calibre of 3.5 cm. at its point of flexure 
into the transverse colon, becomes smaller as it descends, until 
just at the opening into the sac, it is not more than 2 cm. 

The longitudinal muscular fibres are here so closely pressed 
together that the individual taBnise cannot be delimited from 
one another, whilst toward the convexity of the dilatation, they 
radiate out as thick, hypertrophied bundles of muscular fibres. 
The mucous membrane of the colon descendens, besides the 
discoloration described, shows at irregular intervals (0.5 to 
1.0 cm.) small, brown, roundish, spots and points from the size 
of a pin's head and smaller. 

At the entrance into the sac the colon is so narrow that 
it is only with great effort that a finger can be pushed 
through it. 

The mucous membrane of the dilated portion shows every- 
where a rosy color, and is abundantly covered with depressions 
and brownish spots, like those above mentioned, though they 
are somewhat paler here and not so well delimited. No ulcera- 
tion. The thickness of the mucous membrane, which averages 
about 1 mm:, is subject to but slight variations. The muscu- 
lar coat, strongly hypertrophied, has a thickness anteriorly of 
2 mm. ; posteriorly, of 5 mm. 

Looking for the exit into the rectum, there was found at 
the lower and posterior section of the sac a semicircular slit, 
the concavity of which was directed upward and backward. 
A finger pushed through the slit, downward and forward, 
will be observed to glide along the lower wall of the sac, arch- 
ing it forward, for a distance of 8 cm. before it reaches the 
rectum, which had been cut open to the sac. The lower ante- 
rior wall of the sac had here bent over on to the anterior wall 
of the rectum and the two became firmly united. 

The mucous membrane of the rectum showed, with the 
exception of brown spots, like those already mentioned, noth- 
ing abnormal. The rectum was of normal width. 



CHRONIC CONSTIPATION 



77 



The exit of the dilatation was 47 cm. below the entrance, 
whilst the circumference of the sac was 66 cm. 

It took 16 litres of water to fill the sac, and when it was 
held out free by its anterior upper wall, no water ran off. 




1, Descending colon; 2, Dilated sigmoid flexure ; 3, Rectum. 



The reporters, from the arguments adduced in the discussion 
of the case, conclude that the malformation was a congenital 
diverticulum of the sigmoid flexure. 



78 CONSTIPATION IN ADULTS 

4. Diaphragms. — A fold of mucous membrane projects 
into the lumen of the bowel, and, according to its size, 
obstructs more or less the free passage thereof. It may 
stretch from wall to wall, and will then form a complete 
barrier to all communication between the part above and 
that below it ; then, unless it be perforated, life is im- 
possible. It may be in the form of a shelf, and it is in 
this way that it most frequently occurs, leaving a smaller 
or larger passage of intercommunication. 

There may be but one diaphragm, or there may be 
several of them, that is, at different points. 

They are found mainly in the rectum. 

When they occur in the small intestines, death results at a 
more or less early period. 1 

Case 13. M. G., a medical officer in the French service, 
was always constipated from birth. He ate largely, but seldom 
passed a stool oftener than once in two months, and his abdo- 
men assumed a large size. At the age of forty-two his con- 
stipation was usually prolonged to three or four months. In 
1806, after medicines had been taken to procure a stool which 
had not been passed for upward of four months, abundant 
evacuations continued for nine days, and contained the stones 
of raisins taken twelve months before ; but the constipation 
returned. In 1809 the enlarged abdomen became painful, vom- 
iting supervened, and he died at the age of fifty-four, having* 
seldom through life passed more than four or five stools in the 
year. 

On opening the abdomen, a fibrous partition was found that 
obstructed the rectum, about an inch from the anus. Imme- 
diately above this partition the rectum was so enormously 
dilated as to fill all the pelvis and nearly all the abdomen. 
The enormous cloaca contained thirty kilogrammes of brown- 

1 See Part II. 



CHRONIC CONSTIPATION 79 

ish black and very offensive faeces. Its inner surface presented 
gangrenous and ulcerated patches. The lowest part of the 
colon was enlarged to the size of the stomach, which latter, with 
the small intestines, liver, etc., appeared diminished in volume 
and capacity by the pressure of the distended rectum. 1 

Case 14. Quain, Disease of the Rectum, 1854, under the 
head of "Impaction of Faeces," describes the case of a man aged 
forty, who died with a large accumulation of faecal matter which 
was evidently due to the presence of two crescent-shaped shelves 
of mucous membrane, one attached opposite the prostate, the 
other about four inches higher up. Each of these was more 
than an inch in breadth; the circular muscular fibres fully 
entered them and the longitudinal layer dipped in slightly at 
their base. Kohlrausch describes a similar case. 2 



B. Essential Primary Atrophy of the Large Bowel 

Congenital Arrest of Development of the Muscular 
Apparatus of the Boivel 

Nothnagel 3 describes a condition of atrophy of the 
muscles of the large bowel which he regards as a con- 
genital hypoplasia. This condition, which may be present 
in individuals with an otherwise excellent muscular de- 
velopment, is generally connected with a condition of 
chronic constipation. The patients in whom the condi- 
tion was noted had all stated, and their statements were 
confirmed by careful observation, that they went a greater 
or lesser number of days without an evacuation. 

1 Renauldin, Dictionnaire des Sciences Medic, lSlo, Vol. VI., p. 257. 
Copland, Dictionary of Medicine. 

2 Kelsey, Disease of the Rectum. Kohlrausch, Anatomie u. Physiolog, 
der Beckenorgane, Leipzig, 1854. 

3 Beitriige zur Physiologie u. Pathologie des Darmes, Berlin, 1881. 






80 



CONSTIPATION IN ADULTS 



C. Dislocation of the Bowels. Enteroptosis 1 

The intestines may be dislocated, i.e. pushed out of their 
normal position. The small intestines may be forced 
down from the abdominal into the pelvic cavity, and 

in their descent will 
inevitably compel 
the descent of the 
stomach. The large 
bowel may be dis- 
located in its vari- 
ous sections. The 
most common form 
of dislocation is 
cl o w n w a r d, — en- 
teroptosis. The part 
said to be most lia- 
ble to be thus af- 
fected is the right 
colic flexure (flexura 
colica clextra) with 
the transverse colon 
next in the order of 
frequency. From 
what I have seen, I 
am inclined to be- 
lieve that the reverse is true ; that the transverse colon 
is the part most frequently forced out of its normal posi- 

1 Glenard, Lyon Medical, Tome XLVTIL, No. 13 et seq. Cuilleret, 
fitude Clinique sur l'Enteroptose. Gaz. des Hopitaux, September 22, 1S88, 
and No. 105, 1889. Pourcelet, De l'Enteroptose, Paris, 1889. 




(From Rosenheim.) 
C, Caecum; S, Sigmoid flexure. The bowel is inflated 



CHRONIC CONSTIPATION 



81 



tion, and that the right colic flexure is generally but 
secondarily involved. The views of Glenard, upholding 
the former position, are based mainly upon the theoreti- 




(From Rosenheim.) 

F.d, Right colic flexure pushed down and over to the navel; Ct, Transverse colon ; 
L, Liver; M, Stomach. 

cal consideration that the right flexure is but loosely 
attached and rather mobile. However, be this as it may. 
it is the dislocation of the transverse colon that has 
for us clinically the greatest interest. 



82 CONSTIPATION IN ADULTS 

According to the extent of its depression, the transverse 
colon will present changes in its configuration. If it be 
but little depressed, it may have the form of an " M ? " 
whilst if the fall has been very great, it may present 
itself to us in the shape of a "U" or a "V"- 1 When 
the colon is increased in length, as occasionally occurs, 
numerous abnormal twists and flexures are formed which, 
taking sometimes an upward turn, push up the stomach 
and the parts above it. 2 

The etiological factors that have been invoked for the 
production of this condition are numerous. Leaving out 
of consideration the rather few cases that are congenital, 
it may be said that all those conditions that tend to relax 
the tone of the abdominal walls and of the intestines 
are the most fruitful sources of intestinal dislocation. It 
is most frequently seen in women in whom, as a result 
of numerous pregnancies and subsequent neglect of the 
hygiene of the abdomen, the abdominal parietes have 
become flabby, relaxed, even to the extent of a pendu- 
lous belly. In the few cases that have come under my 
observation this was the natural history. This is gen- 
erally admitted. Atonic conditions of the intestines and 
abdominal parietes after prolonged ailments, as typhoid 
fever, rapid emaciation, sometimes constipation of pro- 
longed duration, with great overfilling of these parts of 
the large bowel, 3 lead to enteroptosis. Other causes are 
tight lacing, trauma, acute inflammatory disease of the 
peritoneum. 

1 See history of Case 1, reported by William Levitt. Treves, Intestinal 
Obstruction, p. 124. 

2 Rosenheim, loc. cit. 

3 Treves, Intestinal Obstruction. 



CHRONIC CONSTIPATION 83 

This condition can be recognized in only one way, and 
that is by inflating the bowel with air or gas by means 
of a balloon or siphon (it is not always necessary to clear 
out the bowels before resorting to this , procedure ; accu- 
mulation of faeces does not diminish its effectiveness 1 ), 
and noting the contour of the bowel as outlined upon 
the abdomen. Normally the transverse colon is found 
between the xiphoid cartilage and the umbilicus (males), 
or at the umbilicus or a line or two below it (females) ; in 
enteroptosis it will be found below these points, more 
or less according to the extent of the dislocation. In one 
case that came under my notice, the transverse colon 
was found outlined at the level of the symphysis pubis. 

Enteroptosis is always attended with constipation ; or 
if the coprostasis was Originally the etiological factor 
or pre-existent, it is very much aggravated thereby. 
Krez 2 calls particular attention to this feature. Of the 
five female patients with enteroptosis coming under his 
observation, four had suffered for a long time with most 
obstinate constipation, whilst the remaining one had 
constipation and diarrhoea alternately. In my experience 
(six cases), constipation was always present. 

The obstinacy of the constipation, or its aggravation, 
is due to the fact that the colon is bent upon itself in 
various ways. Although it is true, as Ewald 3 says, that 
under ordinary conditions this would not constitute a 
hindrance, as can be readily seen in the laboratory with 
what force and steadiness the faecal bolus is driven for- 



1 Ewald, Berliner klin. Wochenschrift, 1890. 

2 Muenchener medizinische Wochenschrift, 1892, No. 35. 
8 Loc. cit. 



84 CONSTIPATION IN ADULTS 

ward on its journey to expulsion, nevertheless, it does 
form an obstacle here, for the reason that the vigor in- 
herent in the muscles of the gut is markedly diminished, 
and the powerful aid supplied by a tense abdominal wall, 
the abdominal pressure (Banchjiresse). is wanting, as a 
consideration of the etiological factors will show. 

It is possible that exceptionally we may have produced 
as the result of the dislocation such marked contracture 
in the calibre of the transverse colon as to make it more 
like a cord, corcle collque transverse, as Glenard l calls it ; 
but that it occurs in any way with the frequency he 
would have us believe is open to great doubt. It is not 
possible that such a marked change in the appearance of 
a prominent and exposed portion of the intestine should 
have escaped the attention of the many great anatomists 
and pathologists in their studies upon the human body. 

This point is of great importance from the standpoint 
of prognosis. The evils of enteroptosis can, as is generally 
admitted, be in a great measure remedied ; but we are 
absolutely powerless against an enterostenosis, against a 
contraction of almost the whole length of the transverse 
colon. 

Gruber described a dislocation to the right, of the 
sigmoid flexure, with enormous enlargement thereof. It 
was a post-mortem observation, the cadaver being that 
of a robust man. The abdominal cavity presented all 
the evidences of a long-extinguished peritonitis. The 
flexure lay in the fossa and in the right iliac region, and 
in the boundaries between the epigastric and the meso- 

1 Loc. cit. 



CHRONIC CONSTIPATION 



85 



gastric regions as far as the left hypochondrium. The 
jejuno-ileuni lay to the left of it, and downward, in the 
abdominal and pelvic cavities. 1 





J5 



/A 



m 



W' 



\ 



'X 




A, Jejuno-ileum; B, Large bowel; a, Caecum; b, Ascending colon; c, Transverse 
colon ; d, Sigmoid flexure, a, Shank of the colon ; 0, Shank of the rectum. +, Sec- 
tion of the large omentum that has become adherent to the anterior abdominal wall. 



1 Virchow's Archiv, Vol. 56, p. 432 



S6 CONSTIPATION IN ADULTS 

" The sigmoid flexure proved thus to be an enormously 
lengthened section of the bowel, 47 cm. in length, the shanks 
(Schenkel) of which are united by a long, 39 cm., but, as 
already stated, not broad mesocolon, and therefore they lie in 
closest apposition when they are in a distended state. The 
length of tube of both is 1 m. 22 to 38 cm. ; the width of the 
colon shank (the part which connects the flexure with the 
descending colon), increasing somewhat from below upward, 
is 6.3 to 7.4 cm. : the abnormal width of the rectal shank (the 
part connecting the flexure with the rectum) at the " S-like " 
curved descending portion 10.3 cm. in two directions; at the 
transition into the transversely placed initial section 6.5 and 
8 cm., and at this last part 11.7 and 13 cm. respectively, in two 
directions." 



Section IV. Chronic Constipation from Impaired 
Physiological Function 

By impairment of physiological function we understand 
two very different conditions ; namely : 

1. Perverted action. 

2. Imperfect performance of physiological function. 

It is only to this category of constipation, and more 
particularly to the last subdivision thereof, that the term 
Habitual Constipation can be properly applied, for it is 
only under such conditions that a person may be consti- 
pated for a long time, and still retain a fair condition of 
health. 



CHAPTER VIII 

PERVERTED ACTION; SPASTIC CONSTIPATION 

1. Enterospasm 

It has already been stated in the chapter on the physi- 
ology of intestinal movement that normally the circular 
and longitudinal muscular fibres contract alternately ; in 
this way the chymus is held fast, and not allowed to 
retrograde ; then the section of bowel is shortened, and 
it is pushed onward. Under the influence, however, of 
an abnormal stimulus, the physiological order may be 
perverted, in that the circular and longitudinal muscular 
fibres contract at the same time, synchronously and spas- 
modically, and all further movement on the part of the 
bowel, of the chymus, or of the residual and excrementi- 
tious matter, is inhibited. Moreover, as a result of this 
spasmodic contraction, the calibre of the bowels is greatly 
reduced, at times almost to the size of a lead-pencil. 

This perversion of physiological action, the spasm of 
the intestinal muscles, enterospasm, may be general, i.e. 
involve the whole intestinal tract, from the duodenum 
to the rectum, or it may be partial, limited to a section 
more or less large thereof. It is general in basilar men- 
ingitis, in some of the pathological processes producing 
pressure upon the pons or the medulla oblongata, in 
saturnine intoxication. It is partial in colic, etc. 

87 



88 CONSTIPATION IN ADULTS 

The partial is much more frequent than the general, 
and is most frequently located in the large bowel. 1 

Leaving out of consideration the grave pathological 
conditions in which it is general, enterospasm occurs most 
frequently in gastric and intestinal indigestions ; in con- 
gestions and in catarrhal inflammations of the intestinal 
mucous membrane ; it is of almost constant occurrence 
in colitis. More rarely does it present itself as a pure 
neurosis, as in enteralgia, or as one of the manifestations 
of hysteria or of neurasthenia. 2 

In rare instances it may be observed as one of the 
phenomena of tabes dorsalis {crises e?iteriques s ), even 
though the crises gastriques be wanting. 

The constipation that thus results is known as spastic 
constipation. 

In the majority of instances the constipation is but a 
secondary matter, as can be readily seen from the fore- 
going, that does not call for any special intervention, 
for a special therapy ; that yields or disappears upon 
the proper treatment of the pathological conditions of 
which it is one of the consequences. 

As an idiopathic affection, if such an expression be 
permitted of the condition under consideration, it is of 
very rare occurrence, and is always associated with neuras- 
thenia or hysteria, even though their more characteristic 
features be in abeyance. In the unbalanced condition 
of the nervous system that is the chief characteristic of 
the morbid states just named, even an ordinary stimulus 

1 Rosenheim, Pathol, u. Therap. der Krankh. des Darmes, 1893. 

2 Kaczorowski, Deutsche medic. Wochenschrift, 1882, No. 1. 

3 Rosenthal, Magennenrosen u. Magencatarrh. 



PERVERTED ACTION; SPASTIC CONSTIPATION 89 

that would otherwise have done no more than excite 
normal peristalsis may provoke an enterospasm. 

Symptomatology. — In general enterospasm the abdo- 
men presents a characteristic appearance ; it is sunken 
in, the walls are flattened down, and it has a scaphoid, a 
boat-like, shape, as is very well seen in basilar meningitis 
and in saturnine intoxication. Although in intestinal 
inanition the belly is also very much sunken in, it has 
not the boat-like appearance, nor is the sinking in, the 
flattening down, so marked as in general enterospasm, 
where the calibre of the intestines is reduced almost to 
a minimum. Partial enterospasm, such as is specially 
referred to here, does not cause any change in the con- 
figuration of the belly. The faeces, when the stool is had, 
pass in the form of cylinders of very small calibre, from 
that of a lead-pencil to that of a thin finger, of greater 
or lesser length ; these may be followed by cylinders of 
much greater circumference, or the whole stool may come 
in thin cylinders. Or the faeces may be discharged in 
the form of scibala of greater or lesser size ; but this 
last stool is in no way characteristic. Altogether, the 
quantity evacuated is insufficient. 

A symptom that may or may not be present is pain. 
According to Rosenheim, pain is of frequent occurrence. 
It may be in any part of the abdomen, but is usually 
located about the navel, or in the left lower section of 
the abdomen. It is described as a pressing, a drawing 
together. Fleiner, in his article, does not make mention 
of pain. In the very few cases, within the limitations 
set down here, that have come under my observation, 
there was no pain, only a feeling as if a cord were drawn 



90 CONSTIPATION IN ADULTS 

rather tightly across the abdomen ; a sort of cincture 
feeling, but differing from that of tabes in that it was 
felt only anteriorly (not completely around), and mainly 
in the locality of the transverse colon, in the region 
between the epigastrium and the navel. 

There is really but one characteristic feature, and that 
is the small-calibred cylinders of the stool. 

If the whole evacuation be in this form, and continue 
to be so, then organic stenosis of the intestine must be 
excluded before the case can be set down as one of 
enterospasm. 

2. Enterospasm and Atony 

Partial enterospasm may be associated with atony of 
the intestinal muscles. Under these conditions, the sec- 
tion of bowel above the seat of the spasmodic contraction 
becomes distended with residual or faecal matters and 
with gas. 1 

3. Spasmodic Stricture of the Rectum 

A spasmodic contraction of the rectum has been de- 
scribed, with obstinate constipation as one of the attendant 
phenomena. According to O'Beirne, 2 it is the uppermost 
part or annulus of this section of the intestine that is 
usually the seat of the stricture. It is of exceedingly rare 
occurrence, so rare, indeed, that some excellent authorities 
either deny its existence absolutely, or ignore it in toto 

1 Diseases of the Intestine and Peritoneum, 1879 (Reynold's System of 
Medicine). Article " Enteralgia." Rosenheim, loc. cit. Fleiner, Berliner 
klin. Wochenschrift, January 16, 1893. Cherchewski, Revue de Medic, 
October and December, 1883. 

2 New Views on the Process of Defecation, etc., 1834. 



PERVERTED ACTION; SPASTIC CONSTIPATION 91 

in their writings. 1 It is conceivable, however, and this 
the more so as the occurrence of partial enterospasm is 
generally admitted, that in hysterical and neurasthenic 
states, or under the influence of certain pathological con- 
ditions to be named further on, a spasmodic action of the 
muscles of the rectum might be provoked. The state- 
ments of Mayo, 2 Ball, and the most recent observations 
of Kelsey, 3 seem to confirm this view. 

Symptomatology. — The constipation is rather of the 
acute character. The abdomen is very much distended 
with faeces and gas. There is a great deal of straining 
at stool, and much suffering with it. A bougie, or rectal 
tube, introduced for the purpose of examination, will 
meet with so much resistance that frequently a degree 
of force will be required to overcome it that might, under 
other conditions, prove rather dangerous to the patient. 4 
If the stricture is located lower down, near the anus, the 
finger introduced will be tightly grasped by the spasmodi- 
cally contracting muscle. 5 

4. Spasmodic Contraction of the Sphincter of the 
Anus (without Fissure). Irritable Sphincter 

Much more frequently than the rectum the sphincter 
of the anus may be the seat of the partial enterospasm. 
It becomes then so firmly contracted that defecation is 
almost impossible. 

1 Van Buren, Lectures on the Diseases of the Rectum. Curling, The 
Diseases of the Rectum. Mathews, Diseases of the Rectum, 1898. 

2 Mayo on the Rectum (quoted in Pruitt's Surgery). 

3 Kelsey, Diseases of the Rectum and Anus, New York, 1890. 

4 O'Beirne, loc. cit. 

5 Kelsey, loc. cit. 



92 CONSTIPATION IN ADULTS 

It may be a manifestation of an hysteria, or of a 
neurasthenia, but is most commonly seen in cases of 
sexual neurasthenia, dependent upon morbid states of the 
sexual organs. The obstinate constipation so frequently 
associated with spermatorrhea is undoubtedly very often 
thus produced. 

An enlarged prostatic gland, or an inflammatory con- 
dition of that organ, may give rise to a spasmodic 
contraction of the rectum or anus. An inflamed or 
irritable urethra may likewise do so. In females, a 
spasmodic contraction of the sphincter may present it- 
self in connection with chronic ailments of the genital 
organs. 

Symptomatology. — The chief symptom is the contrac- 
tion of the sphincter, which at times is so great that it is 
only with difficulty and by the use of some force that the 
examining finger can be made to pass, and then not with- 
out considerable pain to the patient. The examining fin- 
ger is tightly grasped by the spasmodically contracted 
sphincter. Occasionally (it might be said frequently) the 
patient has great pain at the end of the evacuation (ob- 
tained by means of purgatives or clysters) produced by 
the spasmodic closure of the sphincter. 

In very severe cases, with almost tetanic spasm, the 
faeces occasionally have a very peculiar appearance ; they 
are flattened out, ribbon-like. 1 

Other symptoms are : more or less uneasiness about the 
anus, which is most marked when sitting, and least when 
lying down ; a feeling of fulness in the perineum ; irritabil- 
ity of the bladder, as shown by the frequent micturition 

1 Henoch, Die Unterleibskrankheiten, 1863. 



PERVERTED ACTION; SPASTIC CONSTIPATION 93 

which, sometimes, is attended by a smarting or burning in 
the urethra. 

The constipation is very obstinate ; I believe, however, 
that it is not the sphincter alone that is responsible there- 
for, but that, by reflex irritation from the sphincter, a nar- 
rowing of the rectum, and a shutting off of the opening 
of the sigmoid flexure or a constriction of the annulus of 
the rectum, as O'Beirne describes it, is provoked. 1 

Schroeder van der Kolk held that the habitual obstipation of 
the alienated arose from a spastic contraction of the descending 
colon inhibiting the onward passage of fsecal matter. From 
this point of view he devised his pills for the treatment of the 
same ; viz. small doses of extractum aloes aquosum, and still 
smaller doses of the tartrate of antimony. 

This opinion was combated by Griesinger upon various 
grounds. Latterly, Professor Rudolph Arndt, 2 in an article 
upon this subject, upholds the views of Van der Kolk that 
spasm is the cause of the constipation, though the same need 
not necessarily be limited to the colon descendens. 

1 Van Buren, Lectures upon the Diseases of the Rectum. Rosenheim, 
loc. cit. Goodel, Journal of the Americ. Medical Associate 1888, latter half, 
p. 15. A. Peyer, Die nervosen Affectionen des Darmes. Wiener Klinik, 
Heft 1, 1893. 

2 Deutsche medic. Wochenschrift, 1881, No. 29. 



CHAPTER IX 

IMPERFECT PERFORMANCE OF PHYSIOLOGICAL FUNCTION 

Atony of the Intestine (Darmatonie). Causes and their 
Mode of Action 

By far the greatest number of the cases of habitual 
constipation that come under our observation are due to 
an imperfect performance of physiological function on the 
part of the intestines, more especially of the large bowel. 1 

Atony (atonia, infirmitas et remissio virium) means a 
loss of vigor, a loss of normal muscular force ; and loss 
of this means an incapability to perform normal func- 
tion. It means also a loss of normal irritability ; a lethar- 
gic state seems to come over the muscle, and it responds 
but slowly and imperfectly to the normal stimulus. 

Muscle and muscular power keep pace with the amount 
of work they are called upon to perform. With active 
exercise of the part or organ, within physiological limits, 
the volume and tone of the muscle is preserved and kept 
at the normal ; with scant use or disuse it loses both in 
volume and vigor. The bowels form no exception to this 
rule. Where from any cause the exercise of their muscu- 
lar apparatus is diminished, it loses in vigor, it loses in 
normal irritability, and, without doubt, to a certain extent, 
in volume. 

1 See also Fleiner, loc. cit. Rosenheim, loc. cit. 
94 



PERFORMANCE OF PHYSIOLOGICAL FUNCTION 95 

The consequence of this atony of the muscular appa- 
ratus of the large bowel is an inability to perform normal 
function, namely, the expulsion of the residual material, 
and constipation results. 

But it has still another effect. Judging by analogy, by 
what we see in the salivary gland, it may be assumed that 
the action of the muciparous glands is stimulated and the 
mucus secreted by them and discharged into the follicles 
is pressed out from them into the canal, where it fulfils 
its function, by the muscular contractions. Where, how- 
ever, these contractions are wanting in so marked a meas- 
ure as in atony, there will then be lack of stimulation, 
and, consequently, lack of secretion ; moreover, much of 
what is secreted will be retained in the follicles, distend 
them, and become a source of irritation. This retention is 
still further favored by the sealing up, as it were, of the 
mouths of the follicles by the stagnating faecal matter. 
Thus the dryness of the faeces, their hardness, and, per- 
haps, also the occurrence of ulcers in certain cases of 
marked constipation, wherein the question has arisen, 
" Which has preceded ?" can be accounted for. 

The causes that lead to such impairment are : 

1. Neglect to attend to the Calls of Nature. — From the 
press of occupation, by reason of the etiquette of our day, 
from lack of opportunity at the proper time (such as is 
provided in most of the large cities of Europe), the call 
of nature is disobeyed. This does not happen once, but is 
of frequent, of daily occurrence, and, as a result thereof. 
a toleration is established both on the part of the mucous 
membrane and of the terminal nerve filaments, and that 
which was regarded by nature as a foreign body to be 



96 CONSTIPATION IN ADULTS 

expelled at the proper time, is now permitted to remain, 
to take up a permanent abode, as it were. 

This is so well-known a fact within the experience of 
the generality of mankind, that it really needs no further 
elucidation. It is fully explained by what has been said 
previously upon the physiology of defecation, and upon 
the well-known facility with which nature becomes habit- 
uated to the presence of extraneous matters and influences. 

2. The Pernicious Habit of Reading at Stool. — A great 
many good people have become and will become consti- 
pated, and cause themselves much annoyance and much 
useless expenditure of money by their attempts to do two 
things at one and the same time ; namely, to empty their 
bowels and fill their heads. 

Cloacina is very exacting, and demands the full concen- 
tration of the mind upon the duties there to be performed. 
It has already been set forth in a preceding chapter how 
the mind regulates, in a great measure, this important 
function, and in that light the deleteriousness of attempt- 
ing to read during the process of defecation is clearly ap- 
parent. The inhibiting influence of the will being diverted 
from the spinal centre controlling the sphincter, the latter 
contracts at once, and, in consequence thereof, the rectum 
falls together, the opening of the sigmoid flexure is shut 
off, and perhaps itself narrowed, and further descent of 
faecal matter prevented. A sort of retroperistaltic wave 
sets in. which may even carry back faeces that have already 
partly descended into the annulus of the rectum. 

I have had this controlling influence of the mind demon- 
strated to me, and have demonstrated it, in another way : 
When the call of nature came, some work or some reading 



PERFORMANCE OF PHYSIOLOGICAL FUNCTION 97 

that was of interest was taken up, the mind plunged in 
medias res, and the call of nature left unheeded. Very 
soon, as the mind became absorbed in the work, the 
desire passed away. Then the thoughts would be again 
turned to the bowels and to the necessity of having a 
stool ; a response, in the form of a call of nature, would 
soon follow; at first slight, then more forcible, until, on 
the way to the lavatory, the call became imperative and 
urgent. 

3. Food Defective in Residual Matter. — It has already 
been shown that a certain amount of residual matter, as 
coarse vegetable fibre, etc., is necessary for the excitation 
of the large bowel to peristalsis. A food too rich in 
nutritive material, and very poor in residual matter, will 
cause constipation. The 4 peristalsis of the large bowel is 
already normally slow, and if there be a lack of stimulus 
or irritation, it will cease almost altogether. In this 
country this factor stands out very prominently. Our 
food, the food of the people, is too rich in nutritive mate- 
rial, and too poor in residual matter : large quantities of 
meats, eggs, bread almost entirely starch, potatoes, and but 
little of the vegetables rich in cellulose. Moreover, great 
numbers of people, either from laziness, or from force of 
circumstances, live almost entirely upon prepared concen- 
trated foods. The fruits that are eaten, as apples, pears, 
are deprived, before being eaten, of that portion which 
cries out to the bowel, like the policeman to the habitue of 
the street corner, " Move on." 

The influence of the character of the food upon peristalsis 
is very well illustrated by the following, from veterinary medi- 
cine. Attention is called in the Magasinf. <7?V gesammte Thier- 



98 CONSTIPATION IN ADULTS 

heilkunde, XXXII. , p. 326, 1 to the fact that the machine-cut 
straw fed to animals, being cut too short, was in many cases the 
apparent cause of obstinate constipation, and frequently of 
death to the animals ; it became packed so tightly in different 
parts of the large bowel, the csecum, the transverse colon, the 
sigmoid flexure, that no medicament was able to move it on. 

Food Deficient in Fats. — We occasionally meet with 
persons who take almost no fat at all with their food ; 
their milk is skimmed, butter they do not eat, and what- 
ever of fat there may be about their meats they cut 
away. They do this from false hygienic considerations, 
as to the preservation of the complexion, as to the main- 
tenance of their digestive powers, or from bad early 
training. 

The residue of unassimilated fat and the fat detritus 
are, no doubt, one of the many factors that excite the 
peristalsis of the bowels, both large and small ; they are 
also an important constituent of the faecal matter, tending 
to keep it soft. A deficiency thereof is therefore apt to 
manifest itself by constipation and an induration of the 
faeces even to such an extent that its discharge through 
the anus may be attended with considerable pain. 2 

4. The Habit of Abstaining from Cold Water. — Many 
people, from crude notions, or through bad advice, abstain 
altogether from the use of cold water ; whatever of fluids 
they take is in the shape of warm decoctions. 

Besides that these decoctions are in the majority of 
instances detrimental by the astringent properties they 
possess (decoctions of tea, of coffee 3 ), they are deleterious 

1 Schmidt's Jahrbiicher, Vol. 137. 

2 See Part II., "Constipation in Infants," Chapter IV. 

3 I refer here only to the abuse of these articles. 



PERFORMANCE OF PHYSIOLOGICAL FUNCTION 99 

by their warmth alone (hot water, infusions of camomile, 
of anise, etc.). The constant application of this warmth 
tends to establish a condition of turgidity of the circula- 
tion in the intestines, impairing thereby the functioning 
of the secreting organs located in the mucous membrane, 
and obtunding the normal sensibility of its nerve fila- 
ments. It has a relaxing effect on the muscle. 

Cold water has a general stimulating, tonifying, effect 
on the intestinal canal both directly and reflexly, upon 
the circulation, upon the nerve filaments, and upon the 
muscular tunics of the intestine, as all who have ever 
experienced a cramp colic after a very cold drink will 
testify to. 

5. Want of Sufficient Physical Exercise. — That a cer- 
tain amount of physical exercise is necessary for the 
well-being of the human body is a well-demonstrated fact, 
patent to all. Exercise stimulates all the physiological 
processes going on within the organism ; the circulation 
is hastened, the respiration is activated so that there is a 
greater exhalation of carbonic acid and increased inhala- 
tion of oxygen ; destructive metamorphosis becomes more 
rapid, and the results thereof are more quickly excreted. 1 
As a consequence, the muscles and other structures are 
invigorated, acquire greater power, and thus become im- 
portant factors in the better execution of physiological 
processes. 

Lack of sufficient exercise naturally entails the reverse 
of all this. Torpidity is the most marked feature, then, 
of the corporeal mechanism ; the circulation becomes 
sluggish, the temperature is lowered, the respiration, i.e. 

1 Carpenter, Human Physiology. Landois, Human Physiology. 



100 CONSTIPATION IN ADULTS 

oxygenation, is retarded, and carbonic acid accumulates 
and tends to further deepen the lethargy, and destructive 
metamorphosis is slowed. As a result of this torpidity, 
the muscles become relaxed and weak. 

A great many people, however, do not get the necessary 
amount of physical exercise, either from indolent habits, 
as we often see it among the more fortunately situated 
class, and particularly among the female portion thereof, 
or by reason of a confining, more especially, a sitting 
occupation. 

In so far as our special subject is concerned, it can be 
readily understood how, from the torpidity of the muscles, 
from the want of the stimulating influence of vigorous 
oxygenation, 1 and from the increase of carbonic acid, all 
the consequences of their inactivity, such persons become 
constipated, even obstinately constipated. 

It is also readily understood how prolonged confinement 
in badly ventilated rooms (working therein — even when 
the work is of rather an active character — and sleeping 
therein) causes constipation. 2 

6. Muscular Weakness of the Abdominal Walls. — This 
may, in some rare instances, arise from some defect of 
muscular development ; most generally it is due to neg- 
lect of the proper measures after parturition. 

A moderate degree of relaxation of the abdominal wall 
will not, in my opinion, — and herein I agree with Rosen- 
heim, — produce, per se, constipation ; but combined with 
some of the other etiological influences named, it is 
certainly most potent in developing a coprostasis, and in 

1 See the chapter on the " Physiology of Intestinal Movement." 

2 See also Birch, Constipated Bowels, 1868. 



PERFORMANCE OF PHYSIOLOGICAL FUNCTION 101 

maintaining it. In its severest form, the pendulous belly, 
it is not only the sole cause of the constipation, but it is 
the most difficult, and not infrequently the insuperable, 
obstacle to the recovery of the patient. 

7. Obesity. — Large deposits of fat about the abdomi- 
nal parietes and the intestines tend to impairment of 
normal muscular vigor, to atony, to constipation. 

8. Prolonged Mental Work ; Prolonged Mental Worry ; 
General Depressing Influences, lower the irritability of the 
nervous system, and, in consequence, all the physiological 
functions are very markedly slowed. 

9. Bad Teeth, or Want of Teeth, prevent perfect masti- 
cation, and compel either the deglutition of badly masti- 
cated food, which will subsequently develop a dyspepsia, 
or a resort to a pap and slop diet. 

10. Old Age. — Besides the feebleness of muscle, the 
torpidity of the secreting organs incident to this epoch of 
life, the lack, in many cases, of good masticating organs, 
the bland character of the food, the want of necessary 
exercise, are important factors in perpetuating a condition 
of constipation. 

I have not counted among the etiological factors the 
habit of pill-taking, which many authors hold as the chief 
cause of the evil, for the reason that I do not believe that 
it is so. 

My experience, both in hospital and private practice, 
has demonstrated to me that " purgative-taking " is not 
the fo?is ct origo of constipation ; rather the reverse, pur- 
gative-taking is the result of constipation. That it finally 
aggravates the derangement, — of this there can be no 
doubt ; the excessive irritation of the purgative exhausts 



102 CONSTIPATION IN ADULTS 

the normal irritability of the intestinal tract, especially 
when the drug is so frequently repeated and in ever- 
increasing doses ; a condition of over-fatigue, of exhaus- 
tion of the muscle, is established. 

An over-indulgence in very coarse vegetable foods may 
produce the same result. 1 The great abundance of coarse 
residual matter causes an excessive irritation of the bowel 
just as do purgatives, and constipation, as a result of the 
exhaustion of the normal irritability, follows. 

TJie prolonged use of warm or lukewarm or emollient 
injections is likewise injurious.* 2 Their mode of action is 
readily understood. They cause turgescence of the parts, 
they enervate the muscle, they dull the normal irritability 
of nerve and muscle. 

Among the incidental causes of constipation, and to which 
Birch 3 has already called attention, is the inadvertent con- 
sumption of certain derivatives of the mineral kingdom, which 
tend to dry up the secretions of the bowels, and to lump and 
harden the feeces. These are alum, the salts of lime, the salts 
of lead, iron, and copper. 

Alum is found in adulterated flour. It is said to be fre- 
quently used by millers to give their flour a lustrous white- 
ness. It is a constituent of many baking powders, and thus 
gets into the bread and other dietary preparations that we con- 
sume. Lime salts : The sulphate of lime is said to be used 
extensively in the preparation of various confections. The 
drinking water may be highly impregnated with the salts of 
lime, as we find in the well water of many country districts. 
Birch states that he has seen a number of cases of constipation 
so produced. In young infants it may be the lime-water added 

1 Rosenheim, loc. cit. Boas, Di'at u. Wegweiser f. Darmleidende. 

2 See Nouveau Dictiomiaire de Med. et de Chirurg. Pratique. Article 
"Constipation." 

3 Birch, Constipated Bowels, 1868. 



PERFORMANCE OF PHYSIOLOGICAL FUNCTION 103 

to their milk. Salts of lead : Various cheap candies are colored 
with the red oxide or yellow chromate of lead. Numerous 
cases of constipation with colic, in children, from the consump- 
tion of such candies have been reported. Even graver con- 
sequences, intoxication and death, have resulted therefrom. 
This offence against public health merits the earnest attention 
of the authorities. The drinking water may be impregnated 
with lead from the pipes through which it is conducted. 
Copper we get with our pickles and various other like condi- 
ments. Iron : The prolonged use of preparations of iron may 
lead to constipation. Drinking water rich in iron, as the 
waters of St. Louis, Michigan, may have the same effect. 

Mode of Action : 

Though some of the etiological factors just named act 
chiefly upon the mucous membrane, obtunding its sensi- 
bility and the sensibility of its nerve filaments (as the 
neglect of the calls of nature, habitual use of food con- 
taining but little residual matter, adulterated food as 
just referred to), whilst others act primarily upon the 
muscular structures (as indolent habits, want of sufficient 
exercise, insufficient oxygenation), and others again upon 
the nerves governing the process of evacuation (as read- 
ing at stool, prolonged mental worry or occupation), nev- 
ertheless, the effect of all these factors is, in reality, one 
and the same, to wit, a loss of normal tone, of normal 
vigor, in the muscular coats of the intestinal tract, — an 
atony of the towel. It can be readily understood that an 
atony could not occur, that the muscles could not fall into 
this lethargic state, if the mucous membrane, if the ulti- 
mate nerve filaments, retained their normal sensitiveness. 

It is generally admitted that, as has been indicated at 
the outset of this chapter, the abnormal — it cannot be 



104 



CONSTIPATION IN ADULTS 



called pathological — condition present in the great ma- 
jority of cases of habitual constipation is an atony of 
the intestine. 1 

An atonic condition of the intestine is not infrequently one 
of the sequelse of the infectious diseases that are attended with 
abundant discharges from the bowels, as typhoid fever, dysen- 
tery, cholera. Here also the atony is, in greater part, a conse- 
quence of the preceding hyper-irritation. 

Atony of the intestine is one of the prominent features of 
chlorosis ; so prominent, indeed, that Sir Andrew Clark was 
disposed to look upon the disease as a copryemia. However 
this may be, this much can be said, that, the disease once devel- 
oped, all the conditions thereof tend to make the coprostasis 
more obstinate. It is a generally admitted fact (and one that 
I hold as of the greatest importance) that there is insufficient 
oxygenation. 2 The stomach is very much disturbed ; the appe- 
tite is poor and perverted ; there is a distaste for the grosser 
kinds of foods, and what nutriment is taken is in concentrated 
form, and even of this but little is consumed. There is a feel- 
ing of languor, of fatigue, which opposes all exercise and active 
exertion ; a loss of tone in muscle, shared by both stomach and 
bowels. 3 



1 Fleiner, loc. cit. Rosenheim, loc. cit. 

2 Osier, Principles and Practice of Medicine, 
u. Hygienische Behandlung der Bleichsucht. 

3 Rosenheim, loc. cit. 



Rosenbach, O., Enstehung 



CHAPTER X , 

SYMPTOMATOLOGY 

Constipation has but few characteristic symptoms ; 
when it has been said that the faecal evacuations are 
retarded beyond the normal period, that the stool is hard 
and dry, and that the person is unable to have a full and 
free discharge without having recourse to a purgative, its 
special features have been described. 

It is true, as has been pointed out, 1 that nature will, 
after a longer or shorter period of time, — from four 
days to three weeks, — make an effort to dislodge the 
accumulated material. It is, however, generally unsuc- 
cessful, always so when the constipation is due to atony, in 
that only a very few hard scibala, which had been pushed 
far down into the rectum by the vis a tergo and had set up 
an unusual irritation about the sphincter, are discharged, 
whilst the bowel above still remains loaded ; and even 
this does not occur frequently, once the constipation has 
become a habit. It is correct, therefore, to count among 
the characteristic features of this derangement the neces- 
sity of a purgative for the production of a full and free 
evacuation. 

In addition to these special features, we have certain 
other phenomena, some of a local, some of a more general 
character, that present themselves to us in constipation. 

1 Kaczorowski, Deutsche mediz. Wochenschrifl, 18S2. 
105 



106 CONSTIPATION IN ADULTS 

General Symptoms. — The tongue is coated ; usually it 
is a thick, white fur ; not infrequently, a yellowish one. 
The breath is offensive. The appetite is poor, maybe nil ; 
sometimes dyspeptic phenomena, as eructations, heavi- 
ness after eating, — even after small meals, — nausea, are 
noted. Occasionally there is a disgust for food ; the per- 
son cannot look at it. A bad taste in the mouth. 

Headache is of frequent occurrence. It is really rather 
a feeling of fulness, of heaviness, of the whole head, or 
more particularly of the frontal portion, than a pain. 

Vertigo, rashes of Mood to the head, are complained 
of. In one case of prolonged constipation, due to anal 
fissure (which is reported more in detail further on), I 
saw profound stupor, so profound indeed that it was only 
with great difficulty that the patient could be aroused, and 
then he would murmur only a few unintelligible words, 
and relapse into his former state. This stupor had lasted, 
at the time I saw him, for over three weeks. 

The perturbation may be more general. It may be a 
feeling of malaise, of hebetude, that renders the person 
incapable of doing any work. It may be a hypochondri- 
acal condition that has supervened ; the person is morose, 
moody, and preoccupied with himself. Again, it may 
manifest itself in a marked irritability ; he (or she) is 
quarrelsome ; nothing is right, nothing is proper, and he 
(or she) has a grievance against the whole of creation. 
I once knew a very eloquent professor who sutler ed from 
chronic constipation in whom this feature stood out so 
prominently as to become quickly known to the students, 
and they could tell at once, when he appeared on the 
rostrum for his lecture, by his manner and look, whether 



SYMPTOMATOLOGY 107 

he had had his clyster and an ample evacuation that 
morning, or whether his duties had kept him therefrom. 
Rosenheim 1 mentions alternate sensations of heat and cold. 
I have not observed this except in neurasthenics, and have 
ascribed it rather to an aggravation of the neurasthenia 
caused by constipation, than to the constipation itself. 

Senator 2 holds that the phenomena are due to intoxication 
by sulphuretted hydrogen gas (SH 2 ), and bases his belief upon 
a case that came under his observation. At a later period, in 
a discussion of dyscrasias, he reaffirmed this view. 3 To this it 
may be opposed that the case upon which this view is mainly 
based could very possibly have been, and the whole history 
points very much that way, one of ilio-csecal intussusception. 
Such a state is, of course, altogether different in its effects upon 
the intestinal processes, and no conclusion could be drawn 
therefrom that would be valid for other conditions. Moreover, 
there is a possibility, even a probability, that in the case re- 
ferred to a considerable quantity of sulphuretted matter was 
introduced from without. Besides all this, the investigations 
of Ruge, 4 of Novack and Brautigam, 5 as already mentioned by 
Rosenheim, very clearly controvert such an opinion. These 
investigators have found that ordinarily the quantity of SH 2 
in the admixture of intestinal gases is less than 0.1 per cent, 
rarely more, even when the faeces are long retained, and such a 
quantity is much too small to cause phenomena of intoxication. 

1 Loc. cit. 

2 Senator, "Ueber eitien Fall von Hydrothionamie," etc., Berlin. Jclinische 
Wochenschrift, 1868, p. 254. 

3 Zeitschrift f. klinische Mediz., Bd. VII. 

4 Ruge, Wien. Sitzungsberichte d. AJcad. der Wissenschaften, 1862, p. 729. 
Foster, Human Physiology. 

5 Nowack u. Brautigam, Muencliener mediz. Wochenschrift, 1890. 

6 The experiments of Bergeon (Nouveau Traitement des Affections des 
Voies Respiratoires, etc., par les Injections Rectales Gazeuses, V. Morel, 
Paris, 1886) and others (Medical Neivs, Phila., 1887), in the treatment of 
tuberculosis, demonstrate that large quantities of SH 2 can be introduced into 
the intestinal tract without causing the least systemic disturbance. 



108 CONSTIPATION IN ADULTS 

The explanation of Rosenheim 1 that they are caused by aug- 
mented putrefaction in the albuminoids, presents as many 
difficulties. 2 

My own opinion is that they are based upon disturbances of 
the nervous, circulatory, and glandular systems of the intestinal 
tract. All of these must suffer, more or less, in constipation, 
from the filling up of the bowel and the pressure necessarily 
exerted by the hardened masses. It may also be possible that 
the diffusion of C0 2 into the intestinal canal 3 is interfered 
with and its consequent accumulation in the blood may con- 
tribute to the production of the perturbations described. 4 We 
see similar phenomena in persons who are very much confined 
to their room, in whom there is an insufficient oxygenation, 
and consequently an increase of C0 2 (beyond the normal limit) 
in the system. 

As to the loss of appetite alone, there is but little diffi- 
culty in its explanation. The atony of the intestinal mus- 
cles soon involves those of the stomach. The movements 
of this latter organ are very much slowed, and conse- 
quently the chymus is retained therein for a much longer 
time. The chemismus itself does not seem to be impaired. 

1 Loc. cit., p. 502. 

2 The investigations of Von Pfungen (Zeitschrift f. klinische Mediz., 
Bd. XXI.) and others have all been made on persons in whom grave or- 
ganic disease, as peritonitis, myelitis, existed, and in whom, therefore, all the 
bio-chemical processes must have been seriously affected. It may be justly 
questioned whether what holds good under those conditions will apply to 
constipation without the co-existence of organic disease ; with an otherwise 
normal condition of the digestive tract, stomach included. Von Pfungen 
himself there says that where the secretion of HC1 in the gastric juice is 
not diminished, the putrefactive processes occurring in the albuminoid mat- 
ters in the large bowel are at about the normal. See "Auto-intoxication," 
in following chapter. 

3 Normally a certain amount of C0 2 is diffused from the blood into the 
intestinal tract. See chapter " Flatus." 

4 See Senator, Berlin, klinische Wochenschrift, loc. cit. Hoppe-Seyler, 
Physiol. Chemie. 



SYMPTOMATOLOGY 109 

In the intestinal canal the digestive process is not 
interfered with ; it is possible that there may be a greater 
splitting up of the albuminoids in the large bowel. 1 

How the bad breath is produced, it is difficult to say. 
Whether it be that some of the inhaled air that is carried 
into the stomach passes thence into the intestinal canal, 
and becoming charged there with the odors from the 
faeces, or with volatile gases, is carried into the circula- 
tion and excreted through the lungs, or that these odors 
or gases pass upwards and through the stomach, and 
mingle with the expired air, is something yet to be 
determined. 

Local Symptoms. — Flatulence : 2 a sense of distention ; 
a feeling of fulness, of heaviness in the belly. The abdo- 
men may be distended symmetrically, or only in part 
thereof. Rolling and purring noises in the bowels. No 
tenderness of the abdomen. Colics not infrequent ; more 
rare in habitual constipation due to atony. Stitches in 
the side, under the liver or under the spleen ; in the back, 
in the lumbar region, sometimes as high up as the inferior 
angle of the scapula, which cause the persons considerable 
suffering and much uneasiness as to the state of their 
liver or of their kidneys. The pains are transitory ; 
there is an interval of rest of longer or shorter duration ; 
then the person feels something shooting up his bowels 
into the locality named, and the pains at once follow ; 
they are wandering, being now on one side, then on the 
other. They are more severe when the person sits or lies 
down, and are relieved by standing or walking. 

1 Von Pfungen. 

2 Accumulation of flatus. 



110 CONSTIPATION IN ADULTS 

All these phenomena are provoked by the distention 
of a loop or loops of intestine by accumulated flatus and 
the irregular peristalsis thus therein excited. A full 
discharge of wind per rectum will quickly effect their 
disappearance. 

Itching at the Anus. — I have known constipated persons 
in whom the call of nature was expressed in an itching 
about the anus, which grew more intense the longer the 
evacuation was delayed, and disappeared at once with the 
discharge. Some of my patients informed me that they 
would have no rest until they had taken an active purga- 
tive, and thoroughly cleansed their bowels. 

If the abdominal parietes be not too thick, the large 
bowel can be very readily palpated. If a condition of 
constipation exists, we will find more or less large fsecal 
masses accumulated therein, which can be readily felt, and 
can be demonstrated to be fsecal matter by the ease with 
which they are broken up with the fingers. They are 
most numerous and most readily felt in the descending 
colon and the sigmoid flexure ; in cases of long standing, 
they can be found almost always in the transverse, and 
even in the upper portion of the ascending colon. 

The fasces are harder and drier than normal ; frequently 
hard and dry, and are usually evacuated in the form of 
scibala, varying in size from a hickory-nut to a horse- 
chestnut ; two to three scibala may be agglutinated to- 
gether, and thus form larger masses. I have seen them 
in the form of cylinders, and so hard that it required an 
axe to break them. They vary in color from a very dark 
brown to a black. There is nothing remarkable about the 
odor. 



SYMPTOMATOLOGY HI 

The special features of enterospasm have been already 
described. 

As in all other ailments, so also here the symptoms 
given may be all present or the greatest part may be 
wanting (and this is not infrequently the case once the 
person has become habituated to the constipation), and 
between these two extremes we have the various and 
numerous gradations. 



CHAPTER XI 

DIAGNOSIS; PROGNOSIS 

Diagnosis — Examination 

The diagnosis alone of constipation is not a difficult 
matter. The patient himself will tell us that he is con- 
stipated, and when he has described to us the period of 
time intervening between one evacuation and the other, 
and when he has informed us that his bowels do not move 
without a purgative, without an injection, we can have no 
further doubts. Some difficulty may be encountered when 
we are confronted with that somewhat paradoxical condi- 
tion where the patient complains of diarrhoea, whilst in 
fact he is constipated. However, even here we can readily 
acquire certainty. A careful examination of the abdo- 
men, a careful examination of the large bowel, of the 
rectum, will disclose to us, if constipation be present, large 
masses of hardened faeces. 

The principal point in diagnosis is to differentiate 
whether the constipation that we are called upon to treat 
is that form which can be called idiopathic — habitual con- 
stipation — or whether it is produced by one of the many 
pathological processes that may give rise thereto. This 
must be done by exclusion. For this purpose we must 
acquire a full history of the patient; we must carefully 
inspect his appearance and that of his body ; we must 

112 



DIAGNOSIS; PROGNOSIS 113 

examine carefully his abdomen, his bowels, his rectum, 
and finally the faeces must be carefully studied, both 
macroscopically and microscopically. 

By the inquiry into his history, we acquire valuable 
data as to the mode of onset of the constipation, the age 
at which it first manifested itself, and its duration. We 
learn whether at any time previous there was pain with 
the stool, whether there is pain with the stool now, before 
or after (ulcer, spasmus, fissure) ; whether the stools were 
admixed with recognizable blood; whether they were 
black and tarry (haemorrhage of the bowel, high up) ; 
whether they contained or still contain large or small 
quantities of mucus, on top or closely intermixed. 

We learn therefrom whether there is any reason to sus- 
pect tubercle. It is very important to know as to the 
probability of a tuberculous condition, for tuberculous 
stricture 1 is a possible factor that must not be overlooked 
in the process of exclusion. We may get data as to the 
family history that will indicate to us whether malignant 
disease should be suspected. We will learn whether the 
patient has ever had strangulated hernia ; whether he has 
ever had dysentery, and possibly a subsequent contraction 
of the lumen of a section of the tube ; 2 whether he has 
had any of the manifestations of syphilitic infection, — 
and syphilis may give rise to a stricture in the bowel. 

We will learn whether the patient has had sexual ail- 
ments, as gonorrhoea, gleet, spermatorrhoea ; whether he 
is addicted to evil practices, etc., all of which are frequent 



1 Treves, Intestinal Obstruction, p. 259. Koenig, Deutsche Zeitschr. f. 
Chirurgie, 1892. 

2 Treves, loc. cit., pp. 255-263. 



114 CONSTIPATION IN ADULTS 

causes, direct or indirect, of obstipation. 1 We will gather 
indications as to whether the patient is a neurasthenic or 
an hysterical individual or not. Finally, we learn whether 
a foreign body should be suspected or not. 

General inspection of the patient, of his body, will give 
weight to what we learn from his history as to tubercle, 
as to cancer. It will inform us whether the liver, the 
kidneys, the heart, must be looked to. 

It will thus greatly facilitate our examination. 

Local inspection of the abdomen will inform us whether 
it is normal or not ; whether it is distended, and if so, 
whether it is symmetrically distended. It will furnish us 
valuable information as to the state of the portal circula- 
tion, and thus inform us as to the condition of the liver. 

By a careful examination of the abdomen, we will be 
able to decide the question of effusions, of gaseous dis- 
tention of the bowels, of tumors of the abdomen. We 
will discover the state of the bowels, of the peritoneum, 
whether they are normal or not. We will learn the con- 
dition of the abdominal walls, whether they have their 
natural firmness, or whether they are relaxed or flabby. 

An examination of the large gut will at once disclose 
whether it is full or empty ; whether it has its normal lo- 
cation. We will learn as to pathological processes within 
or around it; as to growths or foreign bodies. 

A careful examination of the rectum will at once inform 
us as to the presence or absence of accumulations of faeces, 
of haemorrhoids, of polypi, of ulcers, of fissures, of malig- 

1 A. Peyer, Die Nervosen Affectionen des Darmes. Wiener Klinik, Jan- 
uary, 1893. Lowenfeld, Die Nervosen Stoerungen Sexuellen Ursprungs, 
1891. 



DIAGNOSIS; PROGNOSIS 115 

nant disease, of tuberculous, syphilitic, or dysenteric strict- 
ure, of shelves of mucous membrane, of foreign bodies ; 
will at once inform us as to the condition of the mucous 
membrane and parts below, whether they are normal 
or not. 

Of the greatest importance are the macroscopic and mi- 
croscopic examinations of the faeces. By the macroscopic 
examination we note the general appearance of the stool, 
whether it is scibalous or of cylindrical form ; its consist- 
ency, whether very hard, very dry, or only moderately so. 
We see the color thereof, whether brown, or black, or clay- 
colored. We note whether mucus is present in abnormal 
quantities or not. We discover the odor, and thus learn 
whether abnormal putrefactive processes are going on 
within the intestinal tract or not. We receive some indi- 
cations upon the questions of enterospasm. 

A microscopic examination will furnish useful infor- 
mation as to the food of the person ; whether it is too 
concentrated or not ; whether it contains too much indi- 
gestible matter; will inform us as to the presence therein 
of foreign matters, as blood, epithelium, mucus, and 
helminthes. 

The difficulty in diagnosis encountered is chiefly that 
connected with the question of stricture ; firstly, as to the 
presence or absence of a stricture higher up when the 
rectum is found free ; secondly, if a stricture is present, is 
it an organic or a spasmodic stricture ; thirdly, if organic, 
is it interstitial or extraneous (contraction of the inflam- 
matory products of the serous coat ; shrinking of the 
mesentery). 1 

1 Treves, Intestinal Obstruction. 



116 CONSTIPATION IN ADULTS 

Strictures, interstitial, comparatively of not infrequent occur- 
rence, may result from any form of ulcerative disease, and may 
occur in any part of the intestinal tract. Those of the small 
intestines are generally located in the ileum, in the middle and 
lower portions thereof. They are much rarer than those of the 
large bowel, as 1 : 5 or 1 : 6. Of the large bowel (in fact, of 
the whole intestinal tract), the rectum is the most frequent 
seat of stricture ; the sigmoid flexure is next after the rectum 
the most frequent site ; then come, in the order named, the 
colon ascendens, the left colic flexure (flexura coli sinistra), the 
right colic flexure (flexura coli dextra). The caecum is rarely 
ever thus affected. 1 

When the abdominal walls are not too thick or too 
rigid, the large bowel can be readily palpated through 
them. 

Procedure. — The patient (if a child, the bladder must be 
previously emptied) is placed on a firm couch in the horizontal 
position, with the head slightly elevated (by a cushion or by 
the head-piece usually found on couches), with the lower ex- 
tremities extended. The examiner places himself to the right 
of the patient ; he can seat himself, which is more convenient, 
on the couch beside him. 

To facilitate reaching the bowel, the patient is told to keep 
his belly drawn in ; this will shorten the antero-posterior 
diameter of the abdominal cavity, bring the parts more closely 
together and thus more within our reach. 

To obviate the reaction, the muscular contraction and the 
consequent rigidity, which almost always follows when pres- 
sure is made upon the abdominal parietes, various expedients 
may be resorted to : 

(a) The patient is impressed with the necessity of keeping 
his belly loose, relaxed. 

(6) He is told to breathe deeply : this has a very relaxing 

1 Kelsey, loc. cit. Mathews, Diseases of the Rectum. Van Buren, 
Lectures upon the Diseas. of the Rectum. 



DIAGNOSIS; PROGNOSIS 117 

effect upon the abdominal parietes. Furthermore, the deep 
inspirations, by causing deep descent of the diaphragm, will 
depress the bowel, especially the csecum, 2 to 4 cm., and thus 
enable us to locate the latter more readily. 

(c) The left hand is placed upon the abdomen, over the 
linea alba, with the larger part of the hand towards the left ; 
pressure is there made, and all the reaction concentrated under- 
neath it. The region to the right can now be palpated ; no 
reaction on this side now following as long as the pressure 
with the left is continued. 

Obrastzow uses the outer and thenar surfaces of the thumb 
of the left hand, and makes pressure as described. 

Or the left hand can be placed as described above, and firm 
pressure with a pushing away, to the left, motion made ; mus- 
cular contraction will be impossible. This is the expedient 
that I prefer. 

In cases of great rigidity of the abdominal walls, I have 
found it necessary to have the lower extremities flexed ; how- 
ever, only to a moderate extent, i.e. so that the knees were 
just somewhat elevated above the plane of the abdomen. This 
will usually effect a sufficient relaxation without being in any 
way a hindrance to the examination. 

Percussion. — I always make it a point to precede the palpa- 
tion with percussion. Beginning in the right inguinal region 
and running obliquely upward and outward, we have the 
caecum ; upwards to the under border of the liver, the ascend- 
ing colon, then to the right as far as the spleen, the transverse 
colon; here we must make our percussion more carefully, to 
differentiate the stomach from the colon. Then again down- 
ward to the crest of the ilium, the descending colon, and 
downward and inward in the left fossa iliaca to near the 
symphysis pubis, we have the sigmoid flexure. 

From percussion we will derive much valuable informa- 
tion as to the locality of certain special sections of the bowel, 
and also whether these sections are more or less distended 
or not. It will be a sort of outline for us on which to 
palpate. 



118 CONSTIPATION IN ADULTS 

Palpation. — The caecum and the sigmoid flexure may be 
palpated after the fashion of the stomach ; the four fingers of 
the right hand, extended, are brought down perpendicularly 
on the part, with a light but firm pressure, raised and brought 
down again, until the whole section has been gone over. I 
prefer to palpate the csecum in the same way as I do other 
parts of the large bowel, to wit : the four fingers of the right 
hand are placed where the inner or upper border of the caecum 
is supposed to lie, whilst the thumb is placed towards the 
lower or outer border ; gradually the fingers are pressed down 
more deeply, moved about and approached slowly until the 
part desired is felt between them or in the hollow of the hand. 

For the ascending colon the fingers (of the left hand) are 
placed on the right flank. The four fingers, extended, are 
towards the back, whilst the thumb is forward and upward. The 
fingers are pressed in gradually deeper and deeper, other parts 
are pushed aside, and finally the ascending colon is grasped. 

The transverse colon is palpated in the same way, with this 
difference only, that both hands are used, one on either side of 
the umbilicus. The fingers are placed toward the upper, the 
thumb toward the lower border. The same movement already 
described is made ; the fingers are pressed in deeply, gradually, 
and slowly, the parts are rolled between the thumb and fingers 
until finally the bowel is grasped. Once seized, we can follow 
it for a certain distance, three to four fingers' breadth, to either 
side. 1 

To palpate the sigmoid flexure, the examiner can remain in 
the position originally taken to the right of the patient ; then 
in palpating after the last method, he will place the fingers 
towards the outer or lower border, against the ilium, and the 
thumb along the upper border. I have often found it conven- 
ient to change the position, to place myself to the left of the 
patient, facing his feet. This gives me command of the right 
hand in the same position as for the caecum. 

We can facilitate our examination by drawing on the abdo- 
men or by keeping in mind the following lines : 

1 Obrastzow. See further on. 



DIAGNOSIS; PROGNOSIS 



119 



1. From the umbilicus to the right anterior superior spine 
of the ilium. 

2. From the umbilicus to the left anterior superior spine of 
the ilium. These are the linece spino-umbilicalis. 

3. From the right to the left anterior superior spine of the 
ilium. This is the linea inter spinalis. 

The exact point at which to palpate for the various sections 
of the large bowel are shown in the following figure. 




a, Left linea spino-umbilicalis; b, Right linea spino-umbilicalis; e, Linea inter- 
spinalis; c, Caecum and ascending colon; d, Descending colon and sigmoid flexure. 



Cagcum. — For the ca?cum we will begin on the right side, 
on the linea interspinalis upward along to the linea spino- 
umbilicalis ; here we will palpate from below upward, i.e. from 
the crest of the ilium toward the umbilicus. Ordinarily, ac- 
cording to Obrastzow, the csecum is found in the outer or in 
the middle third of the right linea spino-umbilicalis — removed 
about 5 cm. from the spine of the ilium, and not reaching 
the linea interspinalis. 

In cases of constipation the crecum may be filled to almost 
any extent with fa3cal matter and gases, and is, therefore, more 



120 CONSTIPATION IN ADULTS 

or less dilated. It may extend upward to the anterior third of 
the linea spino-umbilicalis and down to the linea interspinalis 
and beyond. In one case of enormous accumulation of faecal 
matter, grape-seeds, grape-skins, etc., the caecum extended 
from the anterior superior spine of the ilium, to the left, to 
within 2 cm. of the linea alba ; downward it filled out the 
whole inguinal region, reaching to the symphysis pubis. 

In another case, a patient aged seventy, suffering with 
chronic cystitis, greatly emaciated, and in whom the large 
bowel was very much distended with gas and stood out promi- 
nently upon the abdomen, the csecum looked like a large 
bologna sausage ; it extended from below the linea interspinalis 
up and somewhat beyond the linea spino-umbilicalis, and from 
the anterior superior spine of the ilium, half-way into the 
middle third of the linea spino-umbilicalis. 

The transverse colon will be found between the umbilicus 
and a line drawn transversely across along the under border of 
the costal arches. In males it will usually be found from 1 to 
3 cm. above the umbilicus ; in females it will be on a line 
running through the umbilicus, or 1 to 2 cm. beneath it. 

There are of course many incidents and accidents that may 
tend to change its position, either depressing or elevating it, as 
has already been described in the chapter on " Enteroptosis." 
All these things must be taken into account in the history of 
the patient, and borne in mind when the physical examination 
is made. 

The sigmoid flexure will be generally found at a distance of 
3 to 5 cm. from the left anterior superior spine of the ilium 
toward the umbilicus on the left linea spino-umbilicalis, and 
crossing, also, downward, the linea interspinalis. 

In cases of constipation it may be distended to almost any 
extent. It may reach from the crest to the supra-pubic space 
and from the anterior superior spine to the umbilicus, depend- 
ing upon the length of time the constipation has lasted, and 
the extent of accumulation allowed. 

Sounds. — The csecum may not give forth any particular 
sound on palpation ; usually, however, a rumbling or purring 
noise produced by the dislocation of flatus is heard. 



DIAGNOSIS; PROGNOSIS 121 

In the transverse colon we may occasionally have a similar 
rumbling sound. 

In the flexura coli sinistra, where we may have marked tym- 
panitic resonance on percussion, we may get a rumbling sound, 
as loud, almost, as that of the caecum and from the same cause. 

In two cases I heard a splashing noise ; but I am not positive 
that it was produced in the bowel. In the one case the stomach 
gave a like splashing noise on palpation. No exact differential 
diagnosis could be made on this point, as the patients would 
not, under any circumstances, consent to the introduction of 
the stomach tube. However, from the location where the 
sound was obtained, far over toward the spleen, and judging 
from the point at which the gastric splashing sound was ob- 
tained in the other case, I believe that the splashing was really 
produced in the flexure, and was not merely a sound made in 
the stomach and conveyed from thence. 

Over the sigmoid flexure we may get the same rumbling, 
purring sounds or none. 1 

In all cases much depends upon the individual tendency to 
the production of flatus, which is more marked in older persons 
than in the young, and greater in those with depressed vitality 
than in persons in robust health. 

Having finished the palpation of the large bowel, we will 
palpate the rest of the abdomen, after the manner already 
described, causing the fingers to penetrate as deeply as pos- 
sible, but without causing the patient any pain. 

By palpation we will learn much as to the state of 
the bowel, whether it is empty or full ; whether it 
contains much of hardened faeces or not. We will also 
learn whether there are any growths within the intes- 
tinal canal, or extraneous to it and pressing upon it. 
In females, we will also learn much as to the condition 

1 Obrastzovv, "Zur physikalischen Untersuclmng d. Magens und Darius," 
Deutsch. Archivf. klin. Mcdicln, Bd. 43. " Ueber d. physikal. Untersuchung 
des Darms," Archivf. Verdauutigskrankheiten, Bd. 1. 



122 



CONSTIPATION IN ADULTS 



of the genital tract, whether the cause of the obstipation 
lies therein or not. 

Great assistance in examining the large bowel will 
be afforded us by inflation. 1 We can insufflate it with 
carbonic acid gas from an ordinary siphon of charged 
waters, 2 or we can inflate it with atmospheric air by 
means of a balloon. 




Arrangement of Apparatus for Inflation by Means of the Siphon (of 
Carbonated Water). 

The gas of one siphon of carbonated water (Seltzer, Vichy), 
amounting ordinarily to 1J to 2 litres, more than suffices to dis- 
tend the large bowel. 



1 Senn, Experimental Surgery, 1889. Behrens, Ueber den Werth der 
kuenstl. Auftreibung d. Dickdarmes mit Gase u. Fluessigkeiten, Goettingen, 
1886. Darnsch, Ueber d. Werth d. k. Auftreibung d. Darmes d. Gase, Ber- 
liner klin. Wochenschrift, 1889. Rosenheim, loc. cit. 

2 Schnetter, Deutsches Archivf. klinische Medicin, Bd. 34. Fougeray, " Des 
Injections Rectaie Gazeuses," Gazette des Hopitaux, 1886, p. 1116. 



DIAGNOSIS; PROGNOSIS 123 

According to the more exact investigation of Damsch, one 
litre of air is all that is usually required. 

The bowel will be outlined to us very clearly upon the 
abdomen, and we will, moreover, have a good percussion 
surface. (By a careful percussion after inflation, we may 
be able to locate either a foreign body or a tumor or an 
induration that might not be otherwise perceptible.) 

By inflation we will very readily learn whether the gut 
occupies its normal location, or whether a dislocation of 
a section thereof has occurred. 




Arrangement of Apparatus for Inflation by Means of the Double Balloon. 

We will learn the size of the large bowel, whether 
it is normal or not ; we will be able to see, to a consider- 
able extent, the configuration of the sigmoid flexure, and 
thus learn whether it is of normal or abnormal conforma- 
tion. 

By inflation we can distinguish whether certain abnor- 
mal growths that we may discover by abdominal palpation 
are of the intestines or not ; moreover, we will learn to 
what organ they do belong. By the distention of the 
bowels with gas the tumor is gradually pushed away, and 
it always retreats in the direction in which the organ of 



124 CONSTIPATION IN ADULTS 

which it is a part is located. Thus, tumors of the kidney 
will be pushed back, behind, and become imperceptible ; 
of the liver, to the right, into the hepatic region ; of the 
spleen, to the left, into the left hypochondrium. Tumors 
of the stomach will be pushed upwards. 

By this method we may be able to discover a stricture 
that could not be found otherwise. The air will pene- 
trate the bowel up to the point of stricture, dilate it, 
and make its outlines distinct on the abdominal parietes ; 
whilst above the stricture, the part not dilating to that 
extent, its contour will not be so clearly outlined on the 
abdominal surface. 

Auscultation can be combined with the insufflation. 
The entrance of air into the free and dilating portion 
will be accompanied by a loud, hissing sound, which can 
be readily heard by the aid of the stethoscope ; whilst 
beyond the point of stricture the sound will be barely 
perceptible. Moreover, on percussion over the region of 
the large gut, as already described, w r e will find that the 
part this side of the stricture, freely insufflated, will give 
a marked tympanitic sound ; whilst above the seat of the 
stricture the sound will, in comparison, be flat. 

If we attempt to inflate the portion beyond the seat 
of stricture, we will find it attended with considerable 
difficulty ; it will require a much longer time, and then 
the distention will not be so marked as that of the portion 
below it. 1 

If it be a question of stricture, it is perhaps better to empty 
the bowel thoroughly, by means of a purge or large clyster, 
before inflating. 

1 Rosenheim, loc. cit. 



DIAGNOSIS; PROGNOSIS 125 

For the examination of the rectum, the patient should 
be placed in Sim's position, on the left side, with knees 
well drawn up. The buttocks being held well apart, 
the anus and exterior surroundings are carefully in- 
spected. 

With the well-oiled finger carefully introduced, the 
rectum can be explored through the whole of its lower 
four or five inches, and its condition learned (haemor- 
rhoids, contraction, etc.). Much may be learned, more- 
over, by this examination, as to the condition of the 
prostate, of the posterior urethra, of the ureters, of the 
ovaries, of the uterus, — all of which are at times impor- 
tant factors in the production of constipation. 

It may be necessary to supplement such an examination 
with an ocular inspection. This will be greatly favored 
by the use of a head-mirror, or of an electric forehead- 
lamp. 

As to the further details regarding the diagnostic 
points of stricture of the various portions of the intestinal 
tract and the various methods of examining the rectum, 
and the instruments employed therefor, the reader is 
referred to the works of Van Buren, Kelsey, Mathews. 
Cripps, and to the article of Dr. H. A. Kelly, 1 in the 
Annals of Surgery, 1895. For special information with 
reference to the diagnosis of abdominal tumors, the works 
of the great gynecologists, the larger treatises upon sur- 
gery, and the lectures upon abdominal tumors lately 
delivered by Dr. William Osier in Johns Hopkins Hospital 
may be consulted. 

1 " A New Method of Examination and Treatment of the Diseases of the 
Rectum and Sigmoid Flexure," Annuls of Surgery^ April, 1895. 



126 CONSTIPATION IN ADULTS 

Peristaltic movements may be visible sometimes upon the 
surface of the belly, when the abdominal walls are very thin 
and relaxed. Abnormally strong peristaltic movements so 
visible, is one of the features of all forms of stricture. They 
begin in the part above the point of contraction ; they may be 
either slow, vermicular, now gently rising, now disappearing, 
or they may manifest themselves as irregular, violent move- 
ments, attended with considerable suffering. The loop of 
intestine promenaded across the abdomen may be so much 
dilated that the small intestine may be mistaken for the large 
bowel, and the latter for the stomach. 

Rosenheim 1 attaches much importance to this phenomenon 
and says : " In doubtful cases, visibility of the peristalsis will 
speak in favor of an already long-existing obstacle." 

Stool. — Cylinders of small calibre, of the size of a 
pencil, or of the small finger, are held to indicate a spas- 
modic narrowing of the lumen of the bowel. They are 
also seen in the stools of persons having a tendency to 
diarrhoea, in whom the faeces contain a superabundance of 
water. 2 Tape-like bands denote a stricture of the rectum. 3 
The absence of these forms does not, however, per se, 
exclude the existence of a stricture, spasmodic or organic. 

Stool in the form of scibala, hard and dry, always 
points to atony of the intestine. 

The indications afforded by color as to the presence 
of blood have been already mentioned. The absence of 
bile is indicated by the peculiar color of the stool ; it is 
an ashy-gray. Such stool is also very sticky, adhering 
like tar to the vessel and has usually a frightful odor 
(wanting in vegetarians). 

1 Loc. cit. 

2 Rosenheim, loc. cit. 

3 Kelsey, Mathews, Ball. 



DIAGNOSIS; PROGNOSIS 



127 



Mucus in considerable quantity upon the stool indi- 
cates a hypersecretion from the rectum. Though this is 
frequently due to a catarrhal condition of the mucous 
membrane, it does not necessarily always indicate this. 
It may result from a temporary irritation of the muci- 
parous follicles produced by some transitory cause, as 
prolonged pressure of irritating particles in the faeces. 
Considerable mucus intermixed closely with the faecal 
matter indicates a catarrhal condition located rather 
higher up, in the small intestine, the caecum, the ascend- 
ing or transverse colon. 

Microscopic Examination of the Faeces. 1 

Haematine, the coloring matter of the blood (recognized 
by formation of Teichmann's crystals), and crystals of 





Crystals of ILematoidin from 

Feces. (JaTcsch.) 



Teichmann's H^emin Crystals. 
(Jaksch.) 



haematoidin indicate the presence of blood, and point to 
a haemorrhagic effusion into the bowel at a more or less 
early date. 

Pus, when recognizable, indicates the presence of an 
abscess, or of an ulcerative process in the intestine, or 

1 See chapter " Faeces." 



128 CONSTIPATION IN ADULTS 

the effusion of pus from an abscess exterior to it into the 
intestine. 

Pus and hcematoidin crystals point to cancerous disease. 
Occasionally the characteristic structural elements of this 
morbid process can be discovered in the faeces. 

Charcot-Leyden crystals will many times denote the 
presence of helminthes. 1 Leichtenstern has found them 
also in the faeces of phthisical persons. 2 

The ova of various intestinal worms may be thus 
discovered. 

Furthermore, and of importance for the special condi- 
tion under consideration, such examination will disclose 
to us whether the person has sufficient residual matter 
in his aliment, or whether it is defective therein. 

For the better examination of the faeces both macroscopically 
and microscopically, the following method is recommended by 
Dr. Herz : A small quantity of the fasces taken from diverse 
portions of the stool is rubbed up in a mortar with some 
water. This addition of water is necessary with all stools, 
even with thin ones, for true watery stools are rather infre- 
quent, and in the former the mucous element having a specific 
gravity nearly like that of the corpuscular neutralizes the in- 
fluence of the centrifuge. A five per cent solution of carbolic 
acid answers very well for this purpose, as it disinfects the 
excrement and destroys or masks to a great extent the dis- 
agreeable and often nauseating odor. When thoroughly rubbed 
up, the mass is subjected to the action of the centrifugal ma- 
chine. As each of the constituent elements of the faeces has 
its particular specific gravity, the mass under the influence of 
the machine must dissolve itself into a number of separate and 
distinct layers. 

1 Rosenheim, loc. cit. 

2 Deutsche medicinische Wochenschrift, 1886. Jaksch, Klinische Diagnostik. 



DIAGNOSIS; PROGNOSIS .129 

On the surface there is a layer of turbid fluid, swarming 
with bacteria. Beneath this are the mighty layers of the vege- 
table constituent, the cellulose. Hereupon follows a black ring 
made up almost entirely of residual muscular fibre. Beneath 
this, and forming about one-eighth of the whole column, we 
find a number of narrow layers which contain the least numer- 
ous, but diagnostically the most important elements, separated 
from each other, as round cells, Clostridia, starch, etc. 

Thus already by mere inspection we may form an idea as to 
the composition of the feces. 

For microscopic examination a portion is removed from the 
individual layer with a long pointed pipette. 1 

When the micro-organisms are the main objects of examina- 
tion, the electrolytic action of the galvanic current may be 
employed for sedimentation, after the method of Winkler and 
Fisher. Two plain iron wires are connected with a battery 
(they worked with two carbon-zinc elements, about 200 milli- 
amperes) and their free ends introduced into the vessel con- 
taining the fluid to be sedimented. Care must be had that the 
free ends do not come in contact with each other and so form 
a short-circuit. This can be readily avoided by keeping them 
apart by means of a small block of wood ; even a large pledget 
of cotton wool will answer. Five to fifteen minutes, according 
to the strength of the current employed, suffice for the sedi- 
mentation. Under the electrolytic influence there is, as is well 
known, a formation of gas ; gas bubbles form a layer of froth 
in the neck of the flask, and beneath this is a turbid layer con- 
taining the micro-organisms, and from this a portion is taken 
up by means of a fine pipette. 

For this process, the fasces are prepared as already described 
for the procedure of Herz. Winkler and Fisher maintain that, 
furthermore, amoeba are much more readily recognized, as the 
current stimulates them into active movement. 2 

For other and further details on this very interesting sub- 
ject, consult v. Jaksch, Klinische Diagnostik, Rosenheim, Darm- 
krankheiten* 

1 Centralblatt f. innere Medicin, 1892, p. 883. 

2 Centralblatt/. innere Medicin, Xo. 1, 1893. 



130. CONSTIPATION IN ADULTS 

The diagnosis of idiopathic constipation having been 
thus arrived at, we will differentiate the atonic from the 
spastic form by the history and symptoms already given 
in preceding chapters. 

The atonic condition of the bowel can be demonstrated in a 
more positive manner, just as it is done for the stomach ; namely, 
by the splashing (plaetschern') sound. It has been found by 
Boas, 1 and confirmed by the investigations of Friedenwald, 2 
that in normal persons 500 to 600, and even 700 c. cm., of water 
must be thrown into the bowel before the splashing sound can 
be obtained ; while in an atonic state of the intestine the splash- 
ing and succussion sound can be heard after 300 to 400 c. cm. 
have been allowed to flow in. 

To bring out this phenomenon, the bowels having been pre- 
viously well moved, warm water (90° to 100° F.) is allowed to 
flow slowly into the bowel ; otherwise, if there be much force 
to the injection, the fluid may pass beyond the ileo-csecal valve 
and give rise to erroneous conclusions. At 300 c. cm. the flow 
is stopped and the bowel palpated ; if the splashing sound is 
not heard, we proceed on to 350 to 400 c. cm., and so on. 

In some few cases this symptom may fail us altogether, and 
still atony be present. 

As to the differentiation between acquired atony and 
congenital atrophy of the intestinal muscles, we must be 
guided by the history of the case. The constipation due 
to the latter condition dates from a very early period of 
life without any appreciable cause, as catarrh, etc., there- 
for. Furthermore, as has been pointed out, there is in 
this condition rather a slowness of discharge than a con- 
stipation. On the whole, however, it may be said that 
congenital atrophy is exceedingly rare, and cannot be 
clearly recognized during life. 

1 Personal communication. 

2 " Atony of the Intestines," Medical News, August 11, 1894. 



diagnosis; prognosis 131 

Prognosis 

It is not at all a question as to life. This, as has been 
already stated at the outset, is not endangered by constipa- 
tion. Exceptionally, however, and it is well to remember 
this, a fatal result may follow. Death has occasionally 
resulted from ileus paralyticus, 1 and I myself saw a case, 
already once referred to here, in which, despite appar- 
ent recovery from the constipation, death from asthenia, 
undoubtedly a consequence of the prolonged retention of 
faecal matters, ensued. 

It is really only a question as to recovery. On this 
head it may be said that it is, as a rule, favorable. Al- 
most all cases, even when considerable dilatation or even 
hypertrophy of the bowel has already occurred, 2 when 
properly managed, recover and resume a normal habit. 
The exceptions to the rule are these : 

I. Where there is a marked dislocation of the bowel of 
long standing, the prognosis is doubtful. 

II. When the abdominal walls are very flabby and re- 
laxed, when the belly is pendulous, so that the Bauch- 
presse, the pressure of the abdominal walls upon the gut, 
is lost, although much may be done by mechanical aids, it 
is, nevertheless, very doubtful whether a restoration to the 
normal can ever be effected. 

III. Old people. Here, besides atony, we have a degen- 
eration, resulting from age and from the prolonged atony. 
There are, besides, other factors, which will be mentioned 
further on, that tend to make the prognosis unfavorable. 

1 See also James T. Goodhart, M.D., in Trans. Clinical Society. London. 
Vol. XIV. A case of ulceration with hypertrophy and dilatation of colon, 
perforation, and peritonitis. 

2 See following chapter. 



CHAPTER XII 

THE CONSEQUENCES OF CONSTIPATION 

Though persons go through life constipated without 
suffering any serious derangement therefrom, it is none 
the less true that in many others it becomes the etiological 
factor, as has been well established by ample clinical 
observation, of various, and even very grave morbid 
processes. 

In constipation there are three prominent incidents : 

(a) There is an inhibition of peristalsis. 

(b) There is an accumulation of residual matter, and, 
as a result of its prolonged sojourn in the bowel, an in- 
spissation, and consequent hardening of the same occurs. 

(c) The circulation of the blood in the bowels, espe- 
cially the venous part thereof, is greatly furthered by the 
peristaltic movements, i.e. by the muscular contractions 
concerned therein. In constipation, however, in conse- 
quence of the inhibition of the peristalsis, of the distention 
of the bowel and the pressure upon it by the accumulated 
and indurated fasces, the circulation is slowed, and a 
turgescence or congestion occurs. 

The ailments which may be developed in consequence 
of these deviations from the normal, and which might, 
therefore, be looked upon as complications of constipa- 
tion, are : 

132 



THE CONSEQUENCES OF CONSTIPATION 



133 



I. Haemorrhoids (cu/xa, blood; peelv, to flow). — That 
haemorrhoids may be directly due to constipation, there 



.V.H.I 



VHM 




VHE 



(From Duret. Archives Gen. de Me'decine, December, 1879.) 

Demi-schematic View of the External Surface of the Ampulla of the 

Rectum. 

Amp., Ampulla; SE., External sphincter; P, Skin of the margin of the anus dis- 
sected up and thrown back; VHI., Internal hemorrhoidal vein; VHM., Middle 
hemorrhoidal vein; VHE. (Subcutaneous), External hemorrhoidal vein. 



can be no doubt. Bodenhammer 1 expressed himself very 
clearly to this effect already at an early date, and it has 
been confirmed in the very recent works of Rosenheim, 2 

1 Bodenhammer, Diseases of the Rectum, 1857. 

2 Krankheiten des Darmes, 1893. 



134 



COXSTIPATIOX IX ADULTS 



Courtois-Suffit, 1 and Mathews. 2 The modus of their pro- 
duction is not difficult to understand. 



HE 




HE 



Demi-schematic View of the Internal Surface of the Ampulla of the 

Rectum. 

Mq, Mucous membrane dissected up and cut away below ; MCI, Muscular coat; 
Spi, Internal spbincter ; SpE, External spbincter ; P, Skin ; HI, Internal hemor- 
rhoidal vein ; HM, Middle hemorrhoidal vein ; HE, External hemorrhoidal vein ; 
III, Small terminal ampulla? (of the vein). 

The hemorrhoidal veins of the rectum, from their 
dependent position, and the fact that the portal system, 
of which they are part, has no valves and that the pres- 

1 Traite de Medecine, Charcot, Bouchard, Brissaud, 1892, Vol. III. 

2 Mathews, Diseases of the Rectum. 



THE CONSEQUENCES OF CONSTIPATION 135 

sure therein is very small, have a natural tendency to 
congestion, which is only obviated by the energetic peri- 
staltic contractions along the whole bowel, especially 
along the large gut. In constipation this vis a tergo is 
wanting. Moreover, other incidents to congestion of the 
rectal veins develop. 

The pressure of the column of the indurated faeces 
upon the upper portion of the rectal parietes must natu- 
rally tend to produce congestion and dilatation in that 
portion of the vessels located in the lower section. 

Owing to the lethargic state of the bowel and the 
hardened condition of the faeces, the pressure of the ab- 
dominal walls (Bauchpresse) will be called in to an undue 
extent to expel the excrementitious matter, and this will 
still further favor the congestion of the lower sections 
of the haemorrhoidal veins. 

Owing to the lack of pressure from behind, the vis a 
tergo above mentioned, the contraction of the muscular 
coat of the rectum upon the vessels — the hemorrhoidal 
vessels pass out through the muscular walls by small 
buttonhole slits which are not bordered by fibrous tissue 
— will tend to the production of a congestion therein 
and of the development of phlebectases. 

From constipation results the free use of purgatives, 
and these are important factors in the production of 
haemorrhoids. 1 

II. Anal Fissure (irritable ulcer 2 ), Erosions about the 
Anus. — This ailment, of which Van Buren 3 says that it 

1 Rosenheim, Kelsey, Mathews. 

2 Van Buren, Lectures on Diseases of the Rectum. 
8 Loc. cit. 



136 CONSTIPATION IN ADULTS 

is capable of causing more intolerable suffering than any 
other that flesh is heir to, is frequently the result of 
constipation. The friction caused by the passage of the 
indurated faeces over the very delicate integument cover- 
ing the anus, combined with the violent efforts of the 
expulsive muscles necessary for its evacuation, and the 
not infrequent forcible dilatation of the anus, can very 
readily produce the crack or fissure which constitutes 
this disease. 1 

III. Typhlitis. (Typhlitis stercoralis 2 ). — This is due to 
the distention of the caecum by the accumulating faecal 
matter; the pressure produced thereby upon its walls, 
and the irritation caused by the induration of the mass 
or the presence of many irritating particles therein. 

IV. Appendicitis. — I hold that this very grave affec- 
tion is in the majority of cases provoked by constipation 
(temporary or habitual). It seems to me more than 
demonstrated by the fact that in the greater part of the 
cases the materies peccans found in the appendix is faecal 
matter. Thus, 

Symonds 3 found that in twenty-three fatal cases of 
appendicitis there were faecal concretions in twenty-two, 
and a foreign body, a grain of wheat, only in one. 

Matterstock 4 found faecal concretions in fifty-three per 
cent of his one hundred and sixty-nine collected cases. 

Fitz, 5 in one hundred and fifty-two cases of perforated 
appendicitis, found faecal masses in forty-seven per cent. 

1 Bodenhammer, On Anal Fissure. Van Buren, loc. cit. 

2 Henoch, Unterleibskrankheiten. 

3 British Medical Journal, December 19, 1885. 

4 Gerhard, Hdb. der Kinderkrankh., IV. 

6 Transactions Assoc, of American Physicians, Vol. I., 1886. 



THE CONSEQUENCES OF CONSTIPATION 137 

Kelynack, 1 who has studied this subject, says : " There 
can be no doubt but that far and away the most frequent 
abnormal contents of the appendix are hardened faecal 
masses, which are frequently infiltrated with lime salts, 
forming distinct concretions." 

At a late meeting of the pathological section of the 
Academy of Medicine (New York), 2 a similar opinion as 
to the predominance of faecal accumulations in the ap- 
pendix was expressed by the gentlemen present. 

From my standpoint, it can be readily understood why 
this should be so. The frequency of the disease is also 
explained. In constipation, the residual matter accumu- 
lates in the caecum and distends it ; the opening leading 
into the appendix is thereby enlarged. 3 Faeces can now 
pass into the appendix, or rather are driven into it by 
the constantly growing mass. Their return, however, 
into the caecum is prevented by this same mass of faecal 
matter, which acts as an obstructing wall against any- 
thing coming from the appendix, and by lack of suffi- 
ciently powerful muscular effort. This faecal matter in 
the appendix, becoming inspissated and indurated, acts as 
an irritant and develops the pathological conditions that 
constitute appendicitis. 

The statement of Fenwick 4 that out of forty-three 
cases of perforative appendicitis, where the previous state 
of health has been recorded, he had found that only in 
three instances had there been any definitive constipated 

1 Kelynack, A Contribution to the Pathol, of the Vermiform Appendix. 
1893. 

2 Meeting in April, 1895. 

3 See case of Morris Price on p. 148. 

4 Clinical Lectures on Obscure Diseases of the Abdomen, 1889. 



138 CONSTIPATION IN ADULTS 

state of the bowels, does not detract from the force of 
my argument. My experience has taught me that many 
more persons are constipated than really have an idea 
that they are so. With some, the evacuation, every 
morning, of a few hard, rocky scibala, requiring con- 
siderable effort for their expulsion ; with others, a scant 
evacuation even every third or fourth day, — is held as 
evidence of regularity, and they will tell their physician, 
when the occasion arises, that their bowels are regular. 
Furthermore, attacks of temporary constipation are en- 
tirely overlooked or forgotten by the great majority of 
people. 

This point, the etiology of this disease, I hold of the 
greatest importance, both as to the therapeutics in the early 
periods of such cases, and the prophylaxis of perforation. 

V. Enteritis Membranacea (Membranous enteritis). — Lit- 
ten l maintains that constipation is, in very many cases, 
the cause of this very troublesome affection. 

VI. Proctitis may result. 2 

A very remarkable case of sloughing of the rectum as a 
consequence of faecal impaction is reported by Dr. W. M. A. 
Wright. 8 

Case 15. The patient, a lady aged sixty-five, who had had 
piles for the last twenty years but who was in other respects 
quite healthy, who led an active outdoor life and whose bowels 
were stated to have always acted most regularly, became ill on 
January 22, 1884. When visited on the following day, she said 
her piles had become inflamed, and on examination a ring of 
them was found external to the anus, nipped by the sphincter, 

1 Berliner klinische Wochenschrtft, 1888, No. 29. 

2 Mathews, loc. cit. 

3 Lancet (London), June 6, 1885. 



THE CONSEQUENCES OF CONSTIPATION 139 

congested, very tender, and irreducible. Anodyne treatment 
was adopted locally and generally. On the 25th profuse leu- 
corrhcea set in and on the 27th complete retention of urine, 
which lasted for eight days. On the 28th diarrhoea came on, 
and the skin over the gluteus maximus on both sides of the 
anus, but especially on the right, became very tense, red, glazed, 
and erysipelatous-looking. On February 1 an external opening 
formed on the right side, about an inch from the anus, and 
almost all the faeces began to pass through it ; by the 4th 
power over the bladder was regained and the inflammation had 
sufficiently subsided to allow of a rectal examination, when an 
enormous mass of faeces was found, broken up by the finger, 
and partially removed by an enema ; daily enemata removed 
the entire mass by the 10th. When the faecal tumor was par- 
tially got rid of, the internal opening was made out clearly 
about one inch and a half up the gut on the right side, and as 
large as a half-crown piece. * On the 14th a secondary abscess, 
with odorless pus, opened into the fistula, after which recovery 
was uninterrupted. 

Dr. Wright remarked that the inflammation of the piles and 
the sloughing of the rectum were undoubtedly caused by the 
pressure of the faecal mass (just as a foetal head may cause 
sloughing of the vagina in the second stage of a tedious labor) ; 
the periproctitis and erysipeloid condition of the skin over the 
buttock was caused by the escape of the faeces into the cellular 
tissue of the ischio-rectal fossa. 

VII. Faecal Tumors (Koth tumor en), Concretions, Entero- 
liths. — By reason of the lethargy of the bowels, and the 
consequent stagnation of faeces, collections of it may form 
in one part of the gut or another, and which, taking on 
diverse shapes and forms, are frequently mistaken for 
dislocated organs, usually for wandering kidney, or for 
abnormal growths, or for abscesses, and errors, therefore. 
made in the diagnosis, prognosis, and, what is worse, in 
the treatment. 



140 CONSTIPATION IN ADULTS 

Case 16. Fcecal tumor mistaken for a nephritis, later on for 
an abscess. (Archives Generales de Medecine, T. XX., 1829, 
p. 581.) 

Lanvin, ost. twenty-five, joiner, of sanguine temperament, 
called Dr. Ducos on July 24, 1828. He had an attack of acute 
nephritis, characterized by great pain in the region of the right 
flank, which travelled down the length of the ureter into the 
bladder. Painful retraction of the testicle of the affected side ; 
moderate thirst ; urine red ; fever slight (leeches, calming po- 
tions). . . . 26th. All the symptoms on the part of the bladder 
have disappeared and the renal pain is greatly diminished. 
The patient not having had an evacuation for four or five 
days already prior to the attack, and the digestive organs 
presenting no point of inflammation, Dr. D. prescribed Ole. 
Ricini 3i. This was rejected by emesis . . . gastritis; delirium 
(leeches, gum water). . . . 28th. The night was fairly quiet ; 
the gastritis has disappeared ; the pain in the flank always 
of the same intensity ; tumefaction in this region ; the belly 
in the rest of its extent is supple (purgative injection). He 
has had several stools, and, in consequence thereof, some loose- 
ness, which lasted for several days. . . . 29th. Consultation ; 
thirty leeches on tumor, which has grown steadily. Belly 
always supple. . . . August 2d. Condition unchanged, tumor 
continues to grow (thirty leeches, poultices over tumor). . . . 
6th. Same condition of tumor ; the centre somewhat fluctuat- 
ing; it seems certain that an opening into it will have to 
be made. Before proceeding to make this opening, Dr. Dar- 
donville proposed the administration of a laxative, that he 
might assure himself that the intestinal canal was perfectly 
free throughout its whole extent, so that in case the abscess 
broke into the bowels, the purulent fluid would have a free 
course. (Ole. Ricini 5i, Syr. Alth. Si, Syr. Caryophylli Rubr. 
3i.) The patient took this mixture in tablespoonful doses 
throughout the day and evening ; in the course of the night he 
had abundant alvine discharges, hard and of grayish color. 
On the following morning the tumor had almost entirely dis- 
appeared. In one word, the patient was cured ; not a trace of 
the abscess existed any more. 



THE CONSEQUENCES OF CONSTIPATION 141 

Four cases are reported by Bright. 1 

Case 17. Accumulation of faeces in the sigmoid flexure of the 
colon, imitating organic tumor. 

August 1, 1840, I was requested to see a young gentleman 
who had been brought to town a few days before, convalescent 
from a severe attack of purpura followed by extensive pleuro- 
pneumonia. He had been seized in the night with bilious 
vomiting, great prostration with writhing pain in the abdomen. 
The pulse was frequent and small, the countenance sunk and 
pallid, and I found considerable tenderness on pressure ; there 
had been but one small motion the day before and another that 
morning, but I could see neither. The first idea which sug- 
gested itself was of some severe obstruction of the bowels, or 
hernia amongst other causes. I inquired for any pain towards 
the groin, and on placing my hand low down in the left iliac 
region, not far from the internal ring, I felt a distinct tumor. 
The part of the abdomen between that and the margin of the 
ribs on the same side was more tender than any other, and 
somewhat tense. I naturally felt uneasy lest some mechanical 
or organic cause should exist. The tumor was more diffuse 
than any ordinary hernial protrusion and yet its more promi- 
nent part felt circumscribed ; it did not dilate on coughing. 
A poultice was applied over the left side of the abdomen, and 
two grains of calomel with half a grain of opium were ordered ; 
effervescent draughts with excess of alkali were given to allay 
the sickness, and a large injection of soap dissolved in water 
was thrown up. These remedies having been repeated two or 
three times, we procured before night a feculent evacuation 
of solid lumps, and the tumor in the iliac region was quite 
removed and all the symptoms subsided. 

Case 18. Fozcal accumulation in the colon, imitating malig- 
nant disease of the liver. 

A. B., a seafaring man aged about fifty-live, was admitted 
into Guy's Hospital under my care, with a hard tabulated 

1 Guy's Hospital Reports, Vol. V., p. 302. 



142 CONSTIPATION IN ADULTS 

tumor, about midway between the point of the ensiform car- 
tilage and the umbilicus, in which he suffered considerable pain, 
both from pressure and without it. His complexion was sallow : 
his bowels stated to be freely open. After a careful examina- 
tion, I felt very little doubt that the tumor was organic and 
connected with the left lobe of the liver, nor did the effect of 
the remedies or the appearance of the patient at all undeceive 
me for some weeks ; but I presently began to suspect that the 
pains of which he made such frequent complaint were rather 
of a spasmodic character, and such as indicated some detention 
of fseces in the intestine. I therefore put him on a more de- 
cided plan of purging than at first, though the bowels had 
never been neglected. He now took repeated doses of comp. 
extract of colcynth, galbanum pill, blue pill, and small quan- 
tities of muriate of morphia. The effect was, after a few days, 
to bring away a quantity of hardened balls of faeces, and in 
proportion to diminish the supposed malignant tumor, till both 
pain and morbid growth and every other symptom of disease 
had disappeared. 

In diseases of the liver with disturbed biliary secretion, 
such lumping together of faeces, more particularly in the 
rectum, is not rare. 

The following very interesting case was communicated 
to me by Dr. Arthur Kahn ? of this city : 

Case 19. Fcecal accumulation mistaken for wandering kidney, 
for tumor of the liver, for a growth connected with the genital tract. 

Mrs. R. E., aged forty-one years; married; has three chil- 
dren. Since three years she has on her right side, about three 
inches from the umbilicus, a palpable tumor, which has grown 
but very slowly. She consulted a number of plrysicians, there- 
fore, and different opinions were expressed as to the organs 
with which it was connected. It was regarded by some as a 
wandering kidney, by others as a tumor of the liver, and still 
others regarded it as connected with the genital tract, and pro- 
posed an operation for its removal. This was declined. 



THE CONSEQUENCES OF CONSTIPATION 143 

After the lapse of the time mentioned she came to me for 
treatment. General history as above given. Present condi- 
tion : she is obstinately constipated. This constipation dates 
far back, and is becoming more and more obstinate. The stools 
cause her great pain, and the faeces come out in hard lumps 
and pieces unless immense quantities of water are frequently 
injected. There is a feeling of fulness in the right hypo- 
chondrium, just above the tumor. Sometimes ructus. After 
eating the feeling of fulness and of oppression is very pro- 
nounced. Above the tumor and outward there is a circum- 
scribed painful zone. 

Patient is very nervous and very irritable. Otherwise in 
good condition, rather vigorous, with a good panniculus. 

Since four days patient has been troubled with an unceasing 
desire to go to stool, with severe colicky pains, without suffi- 
cient discharge. The abdomen is somewhat distended; the 
walls rather tense. She has' been taking opiates without, how- 
ever, being in any way benefited : the pains have become more 
violent, almost intolerable. 

The tumor is located in the region already described, on a 
direct line with the umbilicus ; is of the size of a man's fist and 
rather knobbish. 

An examination of the abdomen showed that the tumor was 
rather round than oval, and was further removed from the 
costal arch than would be the case with movable kidney. The 
urine varied but little in quantity. 

The borders of the liver could be well defined, and it was 
shown that the tumor was entirely independent of this organ. 
As to its connection with the ovaries or uterus, this could not 
be demonstrated with any certainty. 

I prescribed large doses of podophyllin (0.02 pro dosi) with 
strychnine and hyoscyamus (aa 0.0015) and belladonna (0.006) 
every three hours, until an effect was produced. I also ordered 
warm baths, abdominal pack, massage. After seven hours of 
great suffering, so severe that the patient fainted several times, 
she had several evacuations and discharged more than half a 
bucketful of fjeces. In this she found a thick ball, which so 



144 CONSTIPATION IN ADULTS 

distinguished itself by its size, its color, and its hardness, 
that it attracted her attention. It was so hard that it was 
broken up only with considerable difficulty by the use of a 
poker. In the evening I found the patient well, but somewhat 
weak. 

Two months thereafter the tumor reappeared, but under the 
use of purgatives again vanished. It manifested itself again 
nine months thereafter, and the same treatment had the same 
happy result. 

I have not seen the patient since. 

These tumors are formed by the accumulation of fseces 
around a foreign body, — chaff of grain, stone of fruit, seed, 
piece of bone, etc. ; sometimes a particularly hard portion 
of faeces forms the nucleus for further accretions. Very 
frequently the tumors become incrusted by the deposition 
of salts upon them, and then present varying degrees of 
hardness to the touch. 1 

Case 20. An intestinal concretion, the surface of tchich was 
covered with long prismatic crystals of triple phosphate. Dr. 
Hector W. G. Mackenzie (Transactions Pathol. Society, Lon- 
don, Vol. XLIII.). 

A woman aged seventy, who had been a sufferer for many 
years from constipation, took a large dose of salts to relieve 
her bowels, which had not been opened for some days. When 
the bowels were moved, she was much alarmed at finding what 
felt like a hard bony mass presenting itself at the anal orifice. 
This, as afterwards turned out, was a concretion ; but she 
imagined at the time that part of her body, perhaps her back- 
bone, was coming away, and she made every effort to retain it 
in its position. She succeeded in putting it back into the 
rectum, where it remained for four months, at last coming 
away one day in spite of her. At the time it was voided some 

1 Leichtenstern, Ziemssen's Cyclopaedia, Vol. VII. Rosenheim, loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 145 

of it was broken off, so that originally it was larger than it 
now is. It is about the size of the astragalus, and weighs 497 
grains. ... Dr. Bernays has very kindly submitted the speci- 
men to chemical examination, and has reported that the crys- 
tals consist of ammonio-magnesian phosphate, with a trace of 
organic material. 

The mass may become permeated with mineral matter, 
petrified, in fact, and form an enterolith. 

Case 21. Removal of an enterolith, etc. Dr. Sabin (Trans- 
actions of the N. Y. State Medical Association, Vol. II.). 

On September 1, 1884, my father and myself were called to 
see Miss L., aged thirty-five years, who was pale, thin in flesh, 
— almost a skeleton, — and looked careworn and weary. She 
said that she was twice mechanically relieved, years ago, of 
impacted faeces by the breaking down and removal of the 
masses ; that she had much pain in the rectum, and was in 
general a great sufferer ; but although she believed that her 
condition was substantially the same, she would not consent to 
even a digital examination without ether. During the nar- 
cosis I found a hard mass, as large as a turkey's egg, not capa- 
ble of receiving any impression from the finger. ... At the 
appointed time on the succeeding day I again administered 
ether, of which a very large quantity was used. The opera- 
tion, which consisted of dilating the sphincter, and crushing 
the stone with strong forceps and removing it in pieces, lasted 
an hour and ten minutes. . . . An attempt was made to get it 
away whole, but on account of the brittle nature of the shell 
it broke, which very much facilitated its removal. The mass 
that was removed weighed 4|- ounces, more than half an ounce 
having been lost by crumbling. This mass, on close examina- 
tion, was seen to consist of petrified faeces. According to the 
patient's statement, it must have been forming from fifteen to 
seventeen years; still it had never given her trouble until 
within a few weeks past. She would often take laxative medi- 
cine, which would produce stools, but she could not say thai 



146 CONSTIPATION IN ADULTS 

she had ever felt relieved. I had the specimen of stone ana- 
lyzed by Professor W. P. Mason, M.D. He reports the compo- 
sition as follows : Organic matter, phosphate of lime, phosphate 
of magnesia, carbonate of lime, sulphate of lime, silica a trace. 
The main constituent is phosphate of lime. 

Owing to the imperfect depuration, or rather want of 
depuration of the digestive tract, foreign matters, both 
vegetable and mineral, are allowed to collect therein, 
together with the faeces, into a mass, and form concretions 
or enteroliths, which may reach great size. Moreover, by 
reason of the slowness of movement, and consequent long 
retention, deposits may occur from the natural secretions 
of the body, and thus give rise to the formation of an 
intestinal stone. 

Case 22. Concretion, consisting mainly of the chaff of oats. 

Turner reports the case of a man who suffered from obstinate 
constipation ; had already some years before passed two or 
three bullet-like lumps, and since then had a continual uneasy 
and annoying sensation in the left side. After four days of 
absolute constipation, Turner found the abdomen very sensitive 
and detected in the epigastric and umbilical regions a large, 
round, hard, and but slightly movable tumor. He regarded it 
as a scirrhus. Eight days later the tumor began to descend, to 
the great relief and comfort of the patient ; very soon it could 
be felt in the rectum by the introduced ringer, and was quickly 
extracted. It was found to be a concretion made up chiefly 
of the chaff of oats, and was about twice the size of a billiard 
ball. Later on thirteen more such concretions, ranging in size 
from a pigeon to a hen's egg followed. Thereupon the patient 
was completely relieved. 1 

1 Edinburgh Monthly Journal, 1841. Quoted from Henoch, Die Unter- 
leibskrankheiten. Other similar instances are reported by Pereira, Food 
and Diet. Third Edition. (Article "Oats.") 



THE CONSEQUENCES OF CONSTIPATION 147 

Case 23. Enormous concretion of iron and magnesia, removed 
by operation from the lower bowel. Reported by Jonathan Hutch- 
inson (Transactions Pathological Society, London, Vol. VI.). 

A lady past middle age consulted Mr. Lacy, in May, 1853, 
with the account that she had, for more than twelve years, 
suffered extremely from constipation, and most painful sensa- 
tions in the lower bowel. . . . 

On passing the finger into the bowel, a hard uneven sub- 
stance was encountered, having somewhat the shape of a vase 
and being at least fifteen inches in circumference. Its exterior 
did not in the least resemble indurated fseces, feeling indeed as 
hard as a stone and being rough like an oyster. Very fortu- 
nately its interior was not so hard as the outside, otherwise its 
removal might have been impracticable. By the use of a pair 
of long polypus forceps a hole was gradually made into its 
centre, and working outwards from this by degrees the mass 
was broken down and extracted piecemeal by means of a scoop. 
Many sittings were, however, required before this result was 
obtained. . . . 

The outer part of the concretion consisted of concentric 
layers of what looked like a red stone, and which proved on 
examination to be a compound of iron and magnesia. The 
interior was softer, — a mixture of the earthy and ferrugi- 
nous matters with many thousands of strawberry and other 
seeds. . . . 

Nearly thirty years ago the patient had been in the habit 
of taking carbonate of magnesia very frequently, in large doses, 
for the relief of stomach irritation and had also, about the same 
time, used the sesquioxide of iron very freely during attacks 
of tic-douloureux. It was from shortly after this period that 
her first symptoms of intestinal irritation dated. For twelve 
years past she had never taken either of the drugs named. 

The following interesting case was reported in the daily 
press, Baltimore American, and copied in the Cincinnati 
Enquirer, September, 1895. 



148 CONSTIPATION IN ADULTS 

Case 24. The operation of laparotomy performed on Jere 
Hollinger, near Greencastle, Franklin County, resulted in the 
discovery of a hard ball of sawdust. Mr. Hollinger, while 
building a house often chewed a chip, particles of which he 
swallowed, forming the ball. 

A very interesting case of intestinal calculus of almost 
pure cholesterine lias already been given at the outset (see 
page 61). 

*********** 

To what an enormous' extent fseces may accumulate in 
the bowels, and still the patient not be aware that he is 
constipated, is very well shown by the following history 
reported by Morris Price, L.R.C.P.: 1 

Case 25. In August, 1877, I was consulted by a young 
lady, aged twenty-four, who complained of symptoms of indi- 
gestion, occasional vomiting, etc. ... A week later being no 
better I asked her to undress, that I might properly examine 
her. To my astonishment I found that she had large, nodu- 
lated, firm, painless, movable tumors, occupying the lower part 
(and chiefly the left side) of the abdominal cavity. There 
was no gastric tenderness, menstruation had been regular, the 
bowels tvere being moved, in fact there existed a spurious hind of 
diarrhoea. 2, I considered it advisable at once to examine the 
rectum, when I found that this was tremendously distended 
and packed full of dry, nodulated, earthy fsecal matters, the 
anus being in a continual state of patency, due to the paralysis 
of the sphincter by mechanical distention. So much was the 
rectum distended that a child at full period could easily have 
passed through it. . . . This individual, when a child, was in 
the Denbigh Infirmary, under the care, I believe, of Dr. Tur- 
nour, for accumulation in the bowels. 

Getting the patient to the edge of the bed covered with a 
sheet of oilcloth and using plenty of soaped warm water, I 

1 British Medical Journal. 1886, II.. 1211. 2 Italics mine, Illowav. 



THE CONSEQUENCES OF CONSTIPATION 149 

diligently dug away at this mass with my finger (which I think 
better and safer than a spoon) for a considerable length of 
time, finding that the mass was gradually descending as it was 
removed below. Suffice it to say that in this way the whole 
mass in the colon and rectum were cleared. 



Eighteen months afterwards I was called to her again. 

This time I found her just in the same state ; applied the 
same treatment, but not with the same success, inasmuch as a 
mass was left in the sigmoid flexure of the colon which would 
not descend into the pelvis. This could easily be felt by intro- 
ducing a long tube against which the point would impinge, but 
which would give way under a little pressure. Injections were 
of no avail, coming out as administered, owing to the compact- 
ness of the mass. After this attempt to clean the bowels, 
symptoms of complete obstruction supervened, as evidenced by 
her vomiting every meal she took, as well as a stoppage of any 
fa3cal discharge from her bowels. 

These symptoms were not accompanied by any greater dis- 
tention or tenderness of the abdomen, neither was there any 
additional pain ; and in spite of the administration of various 
kinds of purgatives and medicines, as well as enemas, they con- 
tinued for several weeks. . . . While she was away an idea 
on one occasion suggested itself to my mind of doing something 
for her. The idea was to introduce my hand into the gut and 
to push it up as far as possible with the intention of getting 
out and removing the obstruction. ... I operated with the 
assistance of my old master, Dr. Davies of Llanfair, Talhaiarn, 
and Dr. Roberts. My intention was to dilate the anus, but 
finding this impracticable, under chloroform I divided the whole 
structures back to the coccyx. Now I could easily pass my 
hand, and Dr. Roberts passed a long tube in by my wrist, 
through which warm soaped water was injected. At the top 
of the pelvis I came across the big mass which I had so often 
felt and vainly attempted to remove, but iioav I could easily 
crush it. The arm was now withdrawn, when the whole mass 
was expelled. After reintroducing the arm, I found that the 



150 CONSTIPATION IN ADULTS 

colon was in a very abnormal condition, because, instead of 
there being an ascending, transverse, and descending colon, it 
was one tremendously distended chamber} and with my whole 
arm introduced up to the axilla, I could, on account of her 
great emaciation, investigate and manipulate every part of the 
abdominal cavity with the other hand externally. Strange to 
say, in the neighborhood of the right iliac fossa I found an 
opening of an oval shape large enough to allow the passage of 
a good-sized plum (an inch and a half long) with a well-defined 
margin. This was plugged with a lump of hard fsecal matter, 
which was removed and crushed in the large amount of water 
which had by this time been injected. Every part was now 
thoroughly examined, and after satisfying myself that there 
could be nothing more the arm was withdrawn. Sutures were 
carefully inserted, a soft catheter placed in the bladder, and by 
and by a large dose of opium was given. . . . 

After this she got up, gradually resumed her ordinary diet, 
and I took care to watch her carefully for some time with the 
satisfaction to find that the bowels gradually resumed their 
normal functions without the use of aperients or enemas : the 
bowel no doubt, as time went on, in spite of the extraordinary 
distention, resuming its tone and contractile power ; while the 
inestimable advantage of a sphincter capable of discharging its 
functions, has been regained. In this way the patient has kept 
for over seven years. Lastly, what the above opening was, 
unless it was the ileo-csecal valve, I am at a loss to know. 

VIII. Dilatation. — Accumulation of fseces leads to dis- 
tention and to dilatation of the gut. The dilatation may 
be general, involving the whole large bowel from the 
caecum to the anus, as in the case above recited, or par- 
tial, affecting a certain section of the gut only. 

Habershon 2 has reported a number of cases of marked 
dilatation of the caecum. He has seen cases in which the 

1 Italics mine, Illoway. 

2 Habershon, Diseases of the Abdomen, 3d edition, p. 517. 



THE CONSEQUENCES OF CONSTIPATION 151 

colon was so enlarged as to measure twelve to fifteen 
inches in circumference. 

The sigmoid flexure may be the part dilated. 

Case 26. Idiopathic dilatation of the large intestine. Samuel 
Gee. 1 

A boy came under my notice when he was four and a half 
years old. When he was three months old he began to have 
difficulty in passing his motions, which were hard. His belly 
began to swell when he was twelve months old, and afterwards 
it became continuously bigger. When I first saw him he was 
thin. His abdomen was very large ; everywhere resonant to 
percussion ; what looked like coils of intestine were distinctly 
seen ; the tension of the abdomen and the dyspnoea were very 
great. His bowels had not acted for two days, and an enema 
of warm water was given. Fifteen minutes afterwards he 
passed a large quantity of very dark, loose fasces, smelling 
badly. The same evening he began to vomit; he thrice 
vomited large quantities of sour brownish liquid not stercoral 
in smell or look. In short he seemed threatened with ileus. 
Next day I passed a long tube up his rectum as far as it would 
go, and so let off a little loose, slaty colored, stool and a very 
great quantity of wind. His belly became much smaller and 
softer. The vomiting ceased. Appetite for food returned. 
He was able to lie down. After this I tried diverse means to 
get his bowels to contract ; namely, cold douches to the belly, 
friction with stimulating liniment, passage of a tube twice a 
day, and careful bandaging of the abdomen. But to no avail. 
The child became thinner, and after ten days I desisted. He 
seemed much as usual until about a fortnight afterwards the 
urine was observed for the first time to be bloody; it had 
been examined several times before and found to be natural. 
He quickly became worse : very abundant watery diarrhoea set 
in and he died two days afterwards. 

When the belly was opened after death, nothing was to be 

1 St. Bartholomew's Hospital Report?, 1884, XX. 1!>. 



152 CONSTIPATION IN ADULTS 

seen therein save two great pieces of intestine, which were the 
sigmoid flexure hugely distended. It formed two sacs which 
lay side by side, one sac filling up the right half of the belly 
and the other the left. The anus led into the lower end of 
the right sac, which passed upwards and opened under the dia- 
phragm into the upper end of the left sac by a short strait of 
narrower bowel, whence there was a descent into the left half 
of the sigmoid as hugely distended as the right. This descend- 
ing sigmoid sac led, in the left iliac fossa, into the lower end 
of the descending colon. The colon was quite natural, both in 
size and position, and lay hidden behind the enormous sigmoid 
flexure, caecum, and small intestine. Diameter of widest part 
of sigmoid was about four inches, its muscular coat and nerves 
were greatly hypertrophied. The liver was much pushed back ; 
structure of both liver and spleen natural. Kidneys very hard, 
quite like the kidneys of dilated heart ; cortical structures dis- 
tinct, veins dilated. Pelves of kidneys were much dilated ; 
ureters also ; in right ureter was a hemorrhagic ulcerated 
ring, coated with uric acid. The condition of the kidneys and 
ureters was probably due to pressure. . . . At present for want 
of a better explanation I think that mere constipation and retention 
of ivind are the cause of the dilatation. 

Case 27. A case of so-called idiopathic dilatation of the colon. 
By Angel Money and Stephen Paget. 

The patient was first seen by Mr. Paget on September 13, 
suffering from enormous distention ; he measured sixty inches 
round, and twenty-six from the ensiform cartilage to the pubes. 
The whole abdomen was evenly distended, globular, extremely 
tense, and resonant or even tympanitic ; there was no pain or 
tenderness, no movement or gurgling. The condition of his 
lungs was most alarming ; nothing was heard but loud mucous 
rales ; he was very livid, and his breathing was quick and shal- 
low. He just could stand or walk a few steps with support. 
His history was as follows : He was fifty-five years old, and 
for the last five years had been living alone, drinking inces- 
santly both beer and spirits. The distention had been coming 



THE CONSEQUENCES OF CONSTIPATION 153 

on for some months, but had become worse rapidly during the 
last week. He had all the aspects of an habitual drunkard, — 
the typical nose and face, the arteries very tortuous and rigid, 
the legs oedematous, the urine high colored, 1022, albuminous. 
His bowels had always acted regularly, though lately they had 
been somewhat constipated ; they had acted freely the day 
before. 

At the necropsy the enormous distention was still found to 
be present, and to be clearly due to dilatation of the colon. 
But it was not simply a uniform or moderate distention of 
every part of the colon ; the dilatation of the sigmoid flexure 
took the lion's share in the enlargement, there being two large 
sacs, each far bigger than any ordinary dilated stomach ; and 
these two sacs alone would have been sufficient to have caused 
a distention second only in degree to that distention from 
which the patient suffered. 

The contents of these great sacs and of the rest of the dilated 
colon were chiefly a light brown, pultaceous, fermenting, and 
semifluid substance which had the consistence of ordinary 
gruel. In addition to this semisolid stuff there were accumu- 
lations of gas and of fluid ; and, strange to say, at the hepatic 
flexure of the colon, which was not nearly so dilated as the rest 
of the large bowel, there was a big scibalous mass which pre- 
sented in its stony hardness a curious contrast with the pulta- 
ceous substance already mentioned. 

*********** 

In addition to the dilatation of the cavity of the colon there 
was also considerable hypertrophy of its walls, which was espe- 
cially evident in the three longitudinal muscular bands, but 
existed in the circular fibres also. 1 

Despite the statement in the history, it is very clearly 
evident that the patient must have had periods of long 
and obstinate constipation with much accumulation of 

1 Transactions Clinical Society, London, Vol. XXI. 



154 CONSTIPATION IN ADULTS 

faeces and gas. This (with the alcoholic habits of the 
patient) readily explains the dilatation, and demonstrates 
it to be not an idiopathic, but a secondary, dilatation, a 
consequence of constipation. 

*********** 

When the sigmoid flexure is filled with accumulated 
indurated faeces it may be drawn downwards into the 
pelvis by the weight of the mass. By this sinking down, 
the uppermost portion of the rectum is bent upon itself, 
and thus all communication between it and the sigmoid 
flexure shut off. Furthermore it compresses the rectum, 
and thus effects an obstruction. 

When this has occurred, there will be found on exami- 
nation of the rectum upon its anterior wall a protuber- 
ance hard and knotty, which with a little manipulation 
can be pushed upwards and out of the pelvis. In females 
an examination per vaginam will disclose the tumor press- 
ing upon the posterior vaginal wall, and possessing the 
characteristics described. 

The following observation of Asmus x is very character- 
istic : 

Case 28. A young girl, twenty-five years of age, became ob- 
stinately constipated by opiates, which she had taken for the 
relief of violent toothache. The remedies ordered provoked 
stools, but never to the satisfaction of the patient, who always 
felt as if there was still more to be evacuated. Very soon the 
belly became distended, the discharges smaller and smaller, and 
she had violent colics. Medicines and clysters were without 
avail ; the latter were even painful, and but a few drachms of 
fasces would be brought away in the course of several days. 
At the end of half a year the pains were unceasing, and robbed 

1 Casper's Wochenschrift, 1834, p. 166. Quoted from Henoch, loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 155 

the patient of sleep. She became emaciated, had anorexia, 
vomiting, dysuria, a heaviness of the pelvis, and a constant 
feeling as if she must go to stool. But she had no stool, not 
even flatus passed. The rectum being examined a tumor was 
found located upon the anterior wall of the rectum, which it 
pushed back upon the posterior wall, and thus mechanically 
shut off all communication between the parts above and those 
below. The tumor was very tense, of stony hardness, immov- 
able, and on pressure excited a desire to go to stool. Guided 
by this last feature large doses of Ole. Ricini were ordered, 
and efforts made during the process of defecation to push the 
tumor upwards and forwards with the finger introduced into 
the rectum. In three days incredible masses of scybala, hard 
like stone, were passed, whereupon the tumor entirely dis- 
appeared. 

The rectum may become an enormous pouch. In the 
case reported by Dr. I. T. Goodhart of " ulceration with 
hypertrophy, etc., of the colon," the rectum laid open and 
measured from one cut edge to another gave a circumfer- 
ence of seventeen inches. 

Case 29. Dr. Revillout, service of Professor Vulpian. Ga- 
zette d. Hopitaux, 1877, No. 75. 

A man aged forty was admitted to the Charite, ward Saint- 
Jean de Dieu, No. 1. He had an enormous belly which pre- 
sented two distinct zones on percussion ; there was found on 
the inferior section of the abdomen, on the declivity, and when 
the patient was made to change his position, always up to the 
same level, a very apparent dulness, corresponding to a mani- 
fest fluctuation ; in the superior section, on the contrary, a 
tympanitic resonance is heard. 

The intra-abdominal return circulation was evidently very 
much disturbed, for all the superficial veins, both of the thorax 
and of the abdomen, stood out prominently, markedly devel- 
oped, so as to permit of a very active supplementary venous 
circulation. The first impression that was made by these phe- 



156 CONSTIPATION IN ADULTS 

nomena was that this was a case of atrophic cirrhosis of the 
liver, with embarrassment of the portal circulation leading to 
ascites and to engorgement of the superficial veins and to some 
oedema of the lower extremities. This diagnosis once made, 
nothing occurred to contradict it. . . . Questioned as to his 
history, he stated that at his birth he had an imperforate anus ; 
an operation which was successful was made, and for seven 
years thereafter he was compelled to wear a canula in the 
artificially made anus. He attached no importance to this, 
however ; he lived as do other persons, married, and became 
the father of a family. Nevertheless he always felt some em- 
barrassment at stool ; the evacuations were not free, and it 
required much effort to discharge a minimal quantity of faeces. 
In this last period when he came to regard himself as seriously 
sick, he was often seized with paroxysms of suffocation ; he 
could not breathe ; he felt himself choking, and made unheard 
of efforts to unload his belly, and when he succeeded in dis- 
charging a little flatus he felt relieved. In the intervals 
between the paroxysms he was fairly well. 

At the autopsy, in place of the cirrhotic liver which was ex- 
pected, there was found an extraordinary dilatation of the sig- 
moid flexure and of the rectum. These two sections of the 
large bowel formed an enormous pouch, which gave forth a 
loud noise when the scalpel was pushed into it and allowed the 
escape of a quantity of gas and of faecal matter. Measured 
the following day, and although already considerably con- 
tracted, the pouch was 90 cm. long, at least, and 70 cm. in 
circumference at its middle. The anus was found very narrow 
and drawn together on all sides by a very resistant cicatricial 
tissue. The point of the finger could barely be made to pene- 
trate. Immediately above the obstacle the dilatation began. 

There was this peculiarity about the dilatation, that the pari- 
etes, far from being distended and thinned, as would be sup- 
posed, were hypertrophied and fortified in all their constituent 
tissues. The muscular and mucous coats were increased five- 
fold in power. The whole intestinal wall had a thickness of 



THE CONSEQUENCES OF CONSTIPATION 157 

about one-half cm. ; there were seen on the internal surface 
glands equally enlarged and groups of follicles much more 
prominent than is usually the case. 

*********** 

The ampulla of the rectum alone may become largely 
dilated. 1 

As in other organs, so also in the intestines dilatation 
may be attended by hypertrophy. It is mentioned as hav- 
ing been observed in the cases of Gee and Revillout, 
and the following cases are still further and marked 
illustrations : 

Case 30. A case of ulceration with hypertrophy and dilatation 
of colon, perforation, and peritonitis. Dr. James T. Goodhart. 
(Transactions Clinical Society, Vol. XIV.) 

Emma R., cet. seventeen, was admitted into the clinical ward 
of Guy's Hospital. Her father is dead ; the cause of his 
death is unknown. Her mother is still a healthy woman. 
One brother died of rheumatic fever. The patient has always 
had delicate health ; has never had rheumatism. In Decem- 
ber, 1879, her usual health began to fail, but she had no defi- 
nite symptoms — no especial pain. Her abdomen has been 
gradually increasing in size since January of the present year 
(1880), but more rapidly in the last month, and she has been 
worse for three weeks in her general health. She has never 
had severe pain in the abdomen, but has had slight sudden 
pain at times. The bowels have been irregular since January 
— since, that is to say, the onset of the abdominal swelling. 
Sometimes she has had constipation, at others diarrhoea. For 
the last three weeks the latter state has existed ; the bowels 
acting seven or eight times a day, the motions being offensive, 
blackish in color, and for three weeks she has been unable to 
retain her motions. The action of the bowels has caused no 
pain. When admitted she was remarkably anaemic, spare : 

1 See Chapter XXIL, " Atony of the Rectum." 



w 



158 CONSTIPATION IN ADULTS 

she was so bloodless as to suggest that she had lost blood from 
some source. She had an anxious expression ; pulse 128, and 
the abdomen was much distended. It was at first thought by 
the clinical clerk that some abdominal tumor was present, and 
certainly on first placing the hand on the abdomen the case 
had that appearance, for a large, very hard mass was felt to 
occupy the right side from the iliac region to the hypochon- 
drium. But on a more prolonged palpation the tumor dis- 
appeared, to be succeeded by the occurrence of one in the 
epigastrium or left iliac region. Moreover, there was reso- 
nance all over the abdomen, and on inspection the intestine 
could be seen in peristaltic action. The umbilicus was dis- 
tended, but there was no thrill. The abdomen was not tender, 
and there was no evidence of any enlargement of liver or 
spleen. . . . 

Post-mortem Examination. — The abdomen was enormously 
distended and tympanitic. On throwing back the abdominal 
parietes and exposing the intestine, the colon was seen to be 
greatly dilated and occupying the entire front of the cavity. 
The sigmoid flexure occupied the right iliac fossa, having 
pushed the cascum, which was not enlarged, backwards and 
inwards. Tracing the bowel from the ileum along the ascend- 
ing colon, it was found that the large intestine suddenly dilated 
about the hepatic flexure. Below this point it became wider 
and wider, so that the rectum formed a large cylinder. The 
dilated part contained a large quantity of black pultaceous mat- 
ter without scibala, and some of this was exuding into the peri- 
toneum from a small perforation in the sigmoid flexure. The 
peritoneum contained some very foul gas and a small quantity 
of purulent fluid. The dilated colon, particularly its lower 
part, was almost cartilaginous in its toughness, and was hyper- 
trophied to about one-sixth of an inch in thickness. On laying 
it open two superficial ulcers were found close to the anus, each 
the size of half a crown, and more or less oval in shape ; a little 
higher up were two others, and in the sigmoid flexure was a 
large one with sinous margins in the middle of which was a 
small, sloughy patch, with a central perforation previously de- 



THE CONSEQUENCES OF CONSTIPATION 159 

scribed. Higher up still the mucous membrane was reddened 
in several places, and here and there was an erosion. All the 
ulcers presented similar characteristics ; the mucous membrane 
was destroyed, leaving the muscular fibres exposed ; the sur- 
faces were smooth, the edges were thickened and rounded. 
The remainder of the bowel, small intestine, and stomach were 
healthy and contained little faeces or food. There was do 
stricture of the rectum or anus and no fissures. The uterus, 
ovaries, liver, spleen, and kidneys were all healthy. 

Case 31. Dr. E. F. Walsh in the Northwestern Lancet, 
Vol. XIII. , reports the case of a child aged eight years, in whom 
great distention of the gut with hypertrophy of the muscular 
coat were found. The bowel measured from the csecum to the 
rectum nine to ten and a half inches in circumference. The 
hypertrophy of the colon was marked, being greater in the sig- 
moid flexure, where it measured one-eighth of an inch in 
diameter. 

As in the heart, this hypertrophy is the effort of nature 
to counteract the effect of the dilatation. 

Jf. <AL. AL. «J£. Ji. AL. J£. J£. J£. .At. »!/. 

•75* *7t» -ft* -3>*7S> 'Ti* *T? *TF 1^ ^JF *7? 

Copland, quoted by Habershon, 1 mentions oedema of the 
right leg produced by a distended and overfilled coecum. 
This is due to pressure upon the iliac veins. The oedema 
may be about the ankles. 

A tendency to varicocele has also been observed as a 
result of mechanical hindrance to the free return of blood 
from the spermatic vein. 2 

•Jfc. *&l* J£. J*. M, Ji. J£. JA. -\A. .V. .•» 

•w -7i> -n^-JF -?F ^ flP tt tF ^R* ^ 

Distention of the bowels by foeces or gas may produce 
ulceration. Several such ulcers, ulcers by distention. 
have been already reported: 5 In Case 4 reported in my 

1 Habershon, loc. cit., p. 318. 2 Henoch, Die Unterleibskrankh. 

8 See Goodhart, loc. cit. 



160 CONSTIPATION IN ADULTS 

paper, "On Treatment of Intestinal Obstruction by the 
Force Pump/' 1 it is stated: In some portions of the small 
intestine there were noticed small holes, as if made by a 
punch; from the lack of any evidence of severe inflamma- 
tion in the surrounding structure, and from the general 
healthy appearance of the intestine, I ivas led to the belief 
that these were post-mortem occurrences ; if not, they might 
have appeared in the last thirty-six hours, when the vitality 
ivas already very low. These small holes were seen on 
the inner surface of the intestine and did not perforate 
it. They were about the size of the head of a ten-penny 
nail. I could not account for them at the time, but in 
the light of subsequent study it is clear to me that they 
were ulcers by distention, the intestines having been very 
much distended by flatus. 

*********** 

Accumulations of faeces and subsequent dilatation may 
not be unimportant factors in the production of enteropto- 
sis and dislocation. Habershon 2 reports a number of 
cases of dislocation of largely dilated caecum. 

IX. Diverticula. — A further effect of the atony of the 
intestine and consequent prolonged detention of faecal 
matter therein is the formation of diverticula, that is, the 
sacculi or haustra, formed by the circular and longitudinal 
bands of muscular fibres, become distended. The faeces 
contained in them is removed from the onward current in 
the lumen of the bowel — and is thus less accessible and 
more difficult of expulsion — and this difficulty is rendered 
greater by the atony of the muscle. Further accumula- 

1 American Journal of the Medical Sciences, January, 1886. 

2 Loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 161 

tion still further distends the sacculus, and the pressure 
exerted may be so great as to effect a separation of the 
bundles of muscular fibre and a pushing but between them 
of the mucous membrane — constituting a hernia. 
False diverticula of the intestine. Dr. Bristowe. 1 

Case 32. In the second case (which was that of a woman 
cet. sixty-nine, who died of cancer of the stomach, liver, perito- 
neum, and pleura) were found throughout the whole length 
of the colon, but chiefly in the sigmoid flexure, large numbers 
of globular sacculi from the size of a pin's head to that of a 
marble. They all occurred in those portions of the intestine 
to which appendices epiploicaB were attached, and projected into 
them. Their parietes were formed by a prolongation of the 
mucous membrane and by ,the fat of the appendices. The 
muscular coat was for the most part deficient, so that, though 
a few fibres were detected by the microscope in the walls of 
some of the smaller ones, the sacculi may fairly be looked upon 
as hernia of the mucous membrane. Their orifice of communi- 
cation with the intestine was comparatively small, circular, and 
smooth, and each one of them was filled by an indurated lump 
of faeces, which allowed of ready enucleation. No stricture 
was detected, nor any other disease whatever of the large intes- 
tine. Its walls were totally free from cancerous groAvths, and 
no disease existed in the pelvis capable of producing obstruc- 
tion. It seems most probable, however, that the cause produc- 
ing this abnormal condition must have resembled that operating 
in the case of sacculated bladder ; very likely habitual costive - 
ness may have brought about some of the ill effects which 
might be expected to follow on actual obstruction. 

Wallman 2 saw in the case of an invalid who had 
reached the age of sixty-six years, nine true diverticula 
on the lar^e bowel. 

1 Transactions Pathological Society, London, Vol. VI. 
' 2 Virchow's Archie, Vol. XIV., p. 202. 



162 CONSTIPATION IN ADULTS 

They were arranged as follows: One on the colon 
ascendens, three on the transverse colon, three on the 
colon descend ens, and two on the sigmoid flexure. Of 
these, seven were on the free surface of the haustra. 

W. Hale White * presented to the Pathological Society 
a specimen showing diverticula from one-third to one- 
half an inch deep on the descending colon, sigmoid flexure, 
and first part of the rectum. Each diverticulum had a 
fold of mucous membrane around its orifice. 

Case 33. J. V. Lentaigne. (Transactions of the Academy 
of Medicine in Ireland, 1884.) 

On opening the abdominal cavity the large intestine was 
seen to be fringed by a double line of bluish-black, glistening 
tumors, mostly about the size of grapes, but some of them as 
small as swan shot, while a few were nearly as large as a 
pigeon's egg. On handling these they seemed to be quite solid 
and rather hard ; some of them hung from the gut by a short 
but narrow pedicle, whilst others were apparently sessile. . . . 

On opening the gut the central cavity was found to be nar- 
rowed and to contain but little faeces ; the muscular fibres, 
especially the longitudinal set, were very much hypertrophied. 
The mucous membrane presented a number of shallow depres- 
sions, each of which corresponded with one of the tumors on 
the outside. All the tumors were found to be pouches, each 
one tensely filled by a single lump of faeces of ston} r hardness ; 
they were lined by mucous membrane of a brownish color, but 
otherwise apparently normal, and the depressions seen on the 
inside of the gut were formed by a number of folds radiating 
from the tightly closed mouth of each cavit}^. 

These pouches were divisible into two classes, the greater 
number of them consisting simply of the normal pouches of the 
intestine, with more or less narrowing of the neck of the pouch ; 

1 Transactions Pathological Society, London, Vol. XXXVI. 



THE CONSEQUENCES OF CONSTIPATION 



163 



the walls of the cavities were composed of the normal con- 
stituents of the intestinal wall, and their contents could be 
easily squeezed out into the general cavity of the intestine. 
The other set of pouches could 
not be emptied into the gut 
by squeezing, but were easily 
burst by much pressure ; their 
walls were very thin, and 
seemed to consist of mucous 
membrane and peritoneum 
only. 



Although no direct cases 
have as yet been reported, 
it is not difficult to under- 
stand how a per- 
foration of the 
intestine might 
very readily 
occur through 
the mucous mem 
brane in one of the diverticula. 
The force required would not 
be very great, not near that, 
of course, required to rupture 
the three coats. In this way 
the cases of spontaneous rup- 
ture of the intestine are readily 
explained, and the results of 
necropsies seem to clearly point 
thereto. 1 




Fat.se Diverticula. 
(From Treves' latest. Obstruction.) 



1 Herschl, Wiener medizinische Wochenschrift, 1880. No. 1, " Zur Mechanic 
der diastatischen Darmperforationen." 




164 CONSTIPATION IN ADULTS 

False diverticula are occasionally found about the small 
intestine, sometimes in great numbers ; l but whether they 
stand in any relation to the subject under consideration is 
a question. Treves speaks of them 
as diverticula by distention ; if this 
be the cause of their production, 
then they may certainly be related 
to one form of constipation or 

Distention Diverticula, ailOtlier. 

r-:S:S However this may be as regards 
junum, (From sir Ast- th e very mmu te diverticula of the 

ley Cooper's " Hernia.") u 

other sections, it is not improbable 
that diverticula of the ileum, false or true (like Meckel's 
diverticulum), may have the same etiological factor as do 
those of the large bowel. 

Case 34. T. Diller. (Medical News, February 8, 1890.) 
Barbara R., German, cet. sixty-four, married, transferred to 
this hospital from the insane department of the Philadelphia 
hospital. . . . October 20 she vomited several times and 
had some diarrhoea, the stools being light in color. . . . She 
had cold sweats, subnormal temperature, and died October 24. 

Autopsy. — The small intestine normal in calibre, except in 
three or four places where the lumen was contracted from one- 
half to three-fourths. The smallest length of intestine with 
diminished calibre was about four inches long, the longest a 
foot. Proceeding from the ileum, about two feet above the 
ileo-caacal valve, an appendage or diverticulum was discovered. 
It was about four inches in length and with a lumen of suffi- 
cient size to permit the introduction of the middle finger. It 
joined the intestine nearly at right angles and was of a uniform 
diameter in its entire length, though a trifle smaller nearer the 
extremity than at the junction with the bowel, as seen in the 

cut. 

1 Wallmami, loc. cit. Treves, loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 165 

A slight uniform dilatation of the ileum was noted in the 
region of the bowel from where proceeds the process. . . . 
The diverticulum or blind pouch ended in a rounded extrem- 
ity and was filled with soft fsecal matter. . . . The large 




intestine varied greatly in its lumen ; in the ascending, and 
part of the transverse colon, being very large, then a sudden 
diminution in the diameter until it would not permit of the 
introduction of an object larger than the thumb. This con- 
tracted portion of the bowel was about ten inches long. . . . 

Remarks. — As to the diverticulum it might have been con- 
genital or acquired. The fact that the bowel was so enor- 
mously contracted and dilated (a condition I have a number of 
times noted in autopsies upon the insane, and which I believe 
to be due to the habit of constipation) is favorable to the latter 
view. . . . 

X. Hernia may result from violent straining at stool l 
(which the constipated so often do). 

1 Cooper, Surgical Dictionary. 



CHAPTER XIII 

THE CONSEQUENCES OF CONSTIPATION {Continued) 

XI. Diarrhoea with Constipation. — In the course of an 
obstinate constipation, and whilst the gut is still packed 
with hard faeces, a condition that looks very much like 
diarrhoea may supervene. The evacuations from the 
bowels, which previously were inhibited for long periods, 
are now more or less frequent in the day and the stools 
are thin. 

As to the causes that call forth this exaggeration of 
peristalsis, which is, nevertheless, mainly inefficient, I 
believe that, in the first place, it is due to the irritant 
character of the chyme. By the long constipation and 
impaction the digestive function of the stomach has be- 
come impaired, its work is not well done, and the chymus 
is thrown into the intestine in an insufficiently prepared 
state. Here the digestive power being also greatly en- 
feebled, the necessary elaboration does not take place ; 
hence much undigested material remains in the chyme 
and noxious substances are developed therein in its down- 
ward course. It acts thus as an irritant already in the 
small intestine, provokes an exaggeration of peristalsis 
therein, which is communicated to the large bowel as the 
irritant chyme reaches it, and it is carried rapidly through 
and discharged. 

166 



THE CONSEQUENCES OF CONSTIPATION 167 

It may also be that the faecal masses, by the long con- 
tinued pressure exercised, have provoked an undue irrita- 
bility in the muscular coat, perhaps also in the ultimate 
nerve filaments, so that, although unable to throw off the 
impacted masses, the new material arriving is quickly 
expelled. Or it may be due to some special irritation 
about the rectum. 

The fluid material forces or makes its way through the 
gut between one wall of the intestine and the correspond- 
ing side of the impacted faeces. It has been said that the 
column of faecal matter may be hollowed out and form a 
veritable channel, giving free exit to the chyme arriving. 
This, however, is exceedingly rare. 

This diarrhoea differs from the ordinary forms in not 
being diarrhoea at all, in the common acceptance of the 
term, but only a semblance thereof, produced by the fre- 
quent trips of the patient to the vessel or closet. 

Its characteristic features are : 

The stools, though thin, are scant. 

They are not as frequent as would appear from the 
number of times the patient goes to the closet or vessel ; 
many times he has nothing more than a discharge of 
flatus. 

The stools are black, tarry, and offensive. 

They usually lack the products of a catarrhal irritation. 

A striking example we have already had in Case 25, 
reported by Dr. Morris Price. 

A very illustrative case of this kind came under my 
own observation. 

Case 35. April, 1892. I was requested by a colleague to 
see a case with him. Mr. S., cet. fifty-five, has been sick 



168 CONSTIPATION IX ADULTS 

since February, having had, according to his physician, a com- 
plication of diseases ; at first an attack of pneumonia ; then 
diphtheria, and now he is suffering from obstinate diarrhoea. 
Patient is a well-formed individual, who must have been quite 
stout ; belly rather large. He lies in bed in a stupor from 
which he can be roused to a certain extent ; he will mumble 
something in reply to the question, and relapse at once into 
his former state. Face rather ruddy, tongue dry and some- 
what cracked, yellowish coat. Eyes closed, pupils react to 
light. Belly large ; soft ; skin inclined to be flabby : no 
manifestations of pain on pressure. He has had diarrhoea now 
for nearly two weeks, having ten to fifteen stools a day or 
more, and it has not been possible to check it. He gets up 
when he feels the necessity for going to the vessel. The 
matter was discussed, and we finally agreed upon a pill of 
opium and gallic acid, with a little ipecac. This did not 
avail much, and I saw him three or four times more, the medi- 
cine being changed each time, without any benefit. I then 
suggested to the physician in attendance that he wash out the 
bowel. At my next visit I was assured that the bowel had 
been washed out ; but the diarrhoea still continued. I now 
requested to see the wife and questioned her closely. She 
informed me that he would get up very frequently, fifteen to 
twenty times a day, walk over to the chamber, sit a second 
or two and return to bed. Sometimes there would be a table- 
spoonful or two of faecal matter, very thin, in the vessel ; at 
other times nothing. There was at no time, since the begin- 
ning of his ailment, a discharge as large in quantity as one 
commonly sees in diarrhoea. Whether he had any pain at 
stool, she could not say, as no intelligent answer could be 
gotten from him ; but she was under the impression that some- 
times when he was on the vessel he had pain, and she con- 
cluded so from the drawing of the face, the grimaces that she 
several times observed. I concluded that an examination of 
his rectum was a sine qua non; I had the bed drawn to the 
window, patient turned with his back to me, and buttocks well 
drawn apart. At first nothing was noted, but upon pulling 



THE COXSEQUEXCES OF COXSTIPATIOX 169 

apart the margins of the anus, unrolling it as it were, I found 
a fissure. Any further examination of the rectum was pro- 
hibited by the great pain the patient seemed to suffer, as 
indicated by his squirming and moaning on the mere intro- 
duction of the tip of the finger. On the third day thereafter 
the patient was allowed to inhale a little chloroform, and about 
4 p.m. the fissure was incised. The following morning our 
patient was considerably out of his stupor, could talk fairly 
well, his eyes were wide open, but he complained of great 
weakness. The wife informed me that soon after the opera- 
tion he went to the vessel, and he must have had eight or nine 
stools till morning. Each time he passed more than half a 
chamber full of fa3cal sausages, black as tar, and hard as a 
rock. She had tried to break them with an axe but they had 
resisted. Every evacuation was made up chiefly of such cylin- 
ders. A tonic regimen was ^prescribed ; he improved rapidly, 
and in less than a week he was able to get out of bed and to 
walk around. I did not see him after this. 

Four months later he died. I learned subsequently from 
the wife, that though he was up and about, he never gained 
much strength ; never sufficiently to resume his occupation of 
clothing cutter. In the last four weeks of his life he lost his 
strength rapidly. He died of exhaustion, it was said. 

An obstruction of the rectum by foreign material may 
have a like effect. 

Case 36. Reported by J. G. Bride. 1 Man, cet. seventy-two, 
was admitted for diarrhoea, which had been preceded by con- 
stipation. He complained of much pain and a sense of con- 
stant weight at the lower bowel, and of frequent, but difficult 
micturition. I explored the rectum, from which a large hard 
mass, found to be fig seeds, was removed by the handle of a 
spoon and injections of warm water. The means of weighing 
it were not available, but the accumulation in situ could not 
have weighed little short of a pound. The diarrhoea ceased 

1 Lancet, London, 1885, Vol. II., p. 597. 



170 . CONSTIPATION IN ADULTS 

without further treatment, but the bowel did not regain its 
usual power for several days. 

XII. Intestinal Obstruction. Ileus} — Faeces may accu- 
mulate so largely and become impacted so firmly as to 
constitute a veritable obstruction to the onward passage 
of advancing faecal matter. 

A mass of indurated faeces may become dislodged and 
take up a new position in such a manner as to completely 
obstruct the lumen of the bowel, preventing even the 
passage of flatus. 

We may thus have a mechanical ileus developed more 
or less suddenly, with all the symptoms of acute obstruc- 
tion, great pain, inhibition of faecal discharges, rapid 
accumulation of flatus and distention, even to stercora- 
ceous vomiting. 

Faecal concretions (also results of constipation) may 
produce a like condition. 

A section of the gut, usually above the point of great- 
est accumulation, may become paralyzed from over-dis- 
tention by flatus, and in this way a condition of acute 
obstruction, or rather pseudo-obstruction, a sort of ileus 
paralyticus, be developed. 2 

XIII. Torpid Liver (torpor of the liver = deficient secretion 
of bile). 3 — Nothing has been said as yet, to my knowledge, 
as to the relation of hepatic disturbances to constipation, 
in so far as the latter may stand as the etiological factor 
for the former. In a few cases that came under my 

1 From elXo) = to close up, or eiAeco = to twist, 'O lAeds, aAeos- Kraus, 
Krit. Etymol. Med. Lexikon, Gbttingen, 1844. 

2 Henrot, Des Pseudo-Etranglements, Paris, 1865. Henoch, Rosenheim, 
loc. cit. 

3 Murchison, Croonian Lectures, "Functional Derangements of the Liver." 



THE CONSEQUENCES OF CONSTIPATION 171 

observation, in which the habitus and habits of the 
patients were known to me, it has seemed to me that 
the attacks, if I may so call them, of torpid liver stood 
in direct relation to a previously developed constipation. 

XIV. Jaundice may be caused by accumulation of faeces 
and impaction thereof in the right colic flexure and the 
adjacent sections of the transverse colon. (By pressure 
upon the ductus communis.) 

Case 37. Fcecal accumulation in the colon imitating hepatic 
enlargement. Bright (No. 2). 1 

I was requested by Mr. Baldwin to see an old gentleman in 
the city, confined for several days to bed, gradually becoming 
jaundiced ; the tongue furred ; appetite gone ; pulse excited ; 
no sleep ; considerable general enlargement of the abdomen 
with some tenderness ; frequent hiccough and some retching ; 
the bowels were reported to be by no means constipated and 
some of the motions which I saw were well supplied with bile, 
and not scant. On examining the abdomen more carefully, 
there was a distinct hardness discovered, which I concluded 
to be the liver, extending from the margin of the ribs on the 
right side to below the umbilicus. For some days we contin- 
ued to treat him on the supposition that some organic change 
had taken place, and were of course very apprehensive of the 
result. We gradually, however, began to suspect that the 
bowels were scarcely enough acted upon, and we increased our 
purgatives ; the compound decoction of aloes with senna and 
alkali, and the compound galbanum pill with blue pill and 
extract of colocynth were largely administered ; and the quan- 
tity of feculent matter which we daily had the opportunity of 
seeing was almost beyond belief. All the swelling gradually 
subsided ; the dulness on percussion gave way to the clear 
sounds of hollow viscera ; the jaundice disappeared ; the appe- 
tite returned ; and in a few weeks the patient was completely 

1 Loc. cit. 



172 CONSTIPATION IX ADULTS 

restored, and is now in perfect health without the vestige of 
hepatic lesion. In this case I have not the slightest doubt 
that, however much the liver was gorged, as in all probability 
it was, the greater part of the enlargement and dulness of the 
hepatic region was from feculent matter confined in the colon. 

The following very interesting case is reported by Fre- 

richs in his Clinical Treatise on Diseases of the Liver. 

Case 38. A female, aged twenty-five, living in the coun- 
try, who had already aborted several times, believed that she 
Avas in the family way owing to the cessation of menstruation, 
the presence of squeamishness, etc. The ordinary medical 
attendant enjoined the strictest rest, which from her anxiety 
to avoid, at any price, a fresh abortion, she maintained by 
lying for six months upon a sofa. A vaginal examination was 
not permitted ; it was only by feeling the abdomen that the 
medical man recognized a round tumor rising up out of the 
pelvic cavity, and reaching by degrees to the umbilicus. 
Meanwhile the anxiously exj^ected movements of the child did 
not make their appearance ; and notwithstanding the most 
careful nursing, the young woman fell away, became of a pale- 
yellow color, lost her appetite, got oedema of the feet and at 
length complete jaundice. A second medical man, who was 
called in, declared that the disease was an enormous swelling 
of the liver, and denied the existence of pregnancy; in opposi- 
tion to which the first medical man urged the fact (which he 
had observed) of the tumor growing upward from below. 
On my opinion being asked, I examined the abdomen more 
closely. It was remarkably distended and tender ; a tumor 
was seen rising up from the left side of the cavity of the pelvis, 
which felt doughy, and at the umbilicus extended 1^ inches 
beyond the median line ; the csecal region yielded a clear tym- 
panitic sound as far as the linea alba. The hepatic dulness, 
in a line with the mamma, extended from the fifth rib to 8 cm. 
(3i inches) below the arch of the ribs, but in the axillary 
line did not pass beyond the margin of this arch. Trans- 
versely, through the epigastric region, there ran a cylindrical 



THE CONSEQUENCES OF CONSTIPATION 173 

swelling, which was tender upon pressure, and which yielded 
upon percussion, at some places a clear sound, and at others 
a dull one. The bowels were moved every second day, and the 
color of the stools varied, being sometimes pale and sometimes 
dark. Hence, I expressed my opinion that pregnancy did 
not exist (an opinion which was supported by the form, and 
more especially by the doughy consistence of the swelling, 
which could only have arisen from an unusually long sigmoid 
flexure distended with fsecal matter), and that the condition of 
the liver could only be judged of after the evacuation of the 
intestinal canal. By means of clysters and compound infu- 
sion of senna, an extraordinary amount of fseces was evacuated. 
After eight days it was reported to me that the lower tumor 
had disappeared, that the liver was much smaller, and that the 
jaundice had diminished. Three weeks later, when the patient 
presented herself to me, after having drunk of the Kreuzbrun- 
nen Springs of Marienbad, no enlargement of the liver was any 
longer to be detected ; by means of purgatives she had lost 
her hope of a child, and at the same time her anxiety about 
a diseased liver. 

Leube also calls attention to jaundice in this way pro- 
duced. 1 

XV. Atony of the Stomach may result from prolonged 
atonic constipation of the bowels. 2 

XVI. Auto-Intoxication. — It is a question that has 
been much discussed, and has already been referred to 
elsewhere in this book : Does constipation give rise to 
auto-intoxication ? In the solution of this question there 
naturally arises the other question as to the mode of pro- 
duction of the headache, the anorexia, the insomnia of 
the constipated. It has been assumed by some that fchey 

1 Specielle Diagnostik, 1895, Vol. T. 

2 I have observed this in quite a number of oases; shall return to it 



174 CONSTIPATION IN ADULTS 

are the result of intoxication. If this be correct, then 
auto-intoxication may occur. I hold, however, that they 
are not due to auto-intoxication. This I believe to be 
clearly demonstrated by the fact, the common observation 
of the whole profession, that upon a thorough purgation 
these symptoms disappear at once. Intoxication cannot 
be so quickly banished. It is furthermore proven by the 
cases reported of large accumulations of faeces of long 
standing, wherein, if auto-intoxication does so readily 
occur, we should certainly have had it in a marked and 
grave degree. This position is also taken by Bouchard. 
He says: 1 " The objection often raised to the hypothesis 
of auto-intoxication of faecal origin is the fact that consti- 
pation is compatible with good health. If the hypothesis 
were true, auto-intoxication should be realized in its high- 
est degree in the constipated. I answer that constipation 
must be regarded as a protection against auto-intoxication. 
It presumes that all that can be absorbed has been ab- 
sorbed. In constipation there is at first a preliminary 
phase in which the danger of auto-intoxication exists ; in 
the second phase it cannot exist any more." The prelimi- 
nary stage he refers to is only found in the acute forms 
of constipation, in which, owing to acute pathological 
processes, toxic materials are generated in large quanti- 
ties, and by reason of the obstruction, are absorbed. But 
in the other forms of constipation, especially that which 
chiefly interests us here, where there is merely a stagnation 
and induration of faeces, intoxication does not occur. 

There is, however, danger of intoxication, and intoxica- 
tion does in fact occur, when we have a diarrhoea estab- 

1 Bouchard, Les Auto-Intoxications, p. 155. 



THE CONSEQUENCES OF CONSTIPATION 175 

lished with the constipation. As has been already 
pointed out, the fluid matter then in the small intestine 
is abnormal in character, containing irritant and noxious 
substances, and, pouring, out over the impacted faeces, 
the surface of which is softened, additional toxic matters 
are set free; these all coming in contact with the mucous 
membrane, absorption and intoxication may result. This 
poisoning of the system may reach a dangerous degree, 
and even cause death. 

The case of constipation and diarrhoea (Case 35) re- 
ported here by me fully supports this position. The 
patient presented all the evidences of intoxication, and, 
as the history shows, it was under just such conditions 
as above described that the intoxication occurred. And 
though he apparently recovered, I am. nevertheless firmly 
convinced that his system suffered irreparable damage, 
and that his subsequent death was directly due to auto- 
intoxication. 1 

1 See Albu, Ueber die Autointoxicationen des Intestinaltractus, Berlin, 
1895. See also the chapter on " Symptomatology," this book. 



CHAPTER XIV 

THE CONSEQUENCES OF CONSTIPATION (Continued) 

XVII. Functional Disturbances of the Nervous System. 

— Besides the various pathological conditions connected 
directly with the digestive tract, all more or less painful, 
some even attended with no inconsiderable danger, which 
may result from constipation, there are functional dis- 
turbances of the nervous system, of which it is undoubt- 
edly the etiological factor. 

A. Palpitation of the Heart. — This is the most com- 
mon of the functional disturbances of the nervous system 
caused by constipation. During a period of prolonged 
constipation, attacks of palpitation, of hurried cardiac 
action, will come on without there being anything abnor- 
mal discoverable about the heart. In these paroxysms, 
besides the subjective sensation, there is also exaggerated 
activity of the organ ; the heart contractions are aug- 
mented in force and there is increased frequency of 
pulsation. Sometimes there is irregularity of action, as 
manifested by arryhthmia or intermittence. 

These attacks cannot, according to Kisch, who has 
studied this subject carefully, be mistaken for paroxysms 
of angina pectoris, as all the evidences of increase of 
blood pressure by vascular spasms, as coldness and pallor 
of hands, formications, etc., phenomena characteristic of 
angioneurosis, are wanting. 

176 



THE CONSEQUENCES OF CONSTIPATION 177 

In the case related by him, the cardiac impulse was 
strongly visible at the normal point, the pulse was soft 
and 100-120 in the minute. 

With the restoration of the function of the bowels to 
the normal, this cardiac neurosis disappears. 1 

B. Hcemicrania. — Next in frequency of occurrence is 
hsemicrania. Kisch 2 remarks that he has observed in 
quite a number of instances, especially in men and women 
with the mark of abdominal plethora, a venous hyperse- 
mia of the whole abdomen, attacks of hsemicrania, which 
though they obstinately resisted all methods of treatment, 
both local and constitutional, would yield readily to, and 
were permanently cured by, the use of Marienbad-glauber- 
salts. In some of these cases, pains in the epigastrium, 
in the caecum, which would appear as prodroma of the 
typical paroxysm, pointed out the relation of the hgemi- 
crania to the condition of the intestinal tract. He also 
•calls attention to this point, worthy of note, that though 
the administration of an active purgative may cut the 
paroxysm short, nevertheless it is only when the con- 
stipation has been overcome that a permanent cure is 
established. 

C. Tic-douloureux (Trige?ninal Neuralgias). — Charles 
Bell 3 already made the statement that constipation is 
the cause of various facial neuralgias. Stromayer 4 held 
that trigeminal neuralgias were to be regarded as reflexes 
of morbid processes in other parts, principally in the 
intestines, and more particularly of constipation. 

1 Kisch, Berlin, klin. Wochenschrift, 1887. 

2 Ibid. 

3 Practical Essays. 

4 Quoted by Gussenbauer, Prager medicin. Wochenschrift) 1S86. 



178 CONSTIPATION IN ADULTS 

In an address before the Medical Society of Prague, 
Gussenbauer 1 stated that latterly he had found that it 
was not necessary to operate as frequently in cases of 
trigeminal neuralgia as he had formerly believed. In 
twenty-eight cases of this form of neuralgia — cases of 
central origin being, of course, excluded — he had oper- 
ated only four times. He had found that a methodical 
treatment, with a view to a restoration of the normal 
functioning of the bowels, is the best method of curing 
obstinate and painful neuralgic affections. The following 
very interesting case reported by him is excerpted here 
in brief. 

Case 39. Mrs. , cet. forty-two. She was married at 

eighteen. After her last confinement her menses became 
irregular, she had fluor albus, and was generally invalided. 
She was treated with cauterization ; curetting ; she took cures 
at various health resorts (Badekuren), but was never com- 
pletely restored. In the last five years an obstinate constipa- 
tion had supervened upon her other troubles ; stools every two 
or three days hard and scibalous. Intermittently purgative 
diarrhoea. Three years ago she had an attack of trigeminal 
neuralgia. In 1883 she consulted Bamberger and Nothnagel, 
and was treated with the usual remedies and relieved. The 
relief, however, did not last long, the pains returned with 
increased severity, and she was referred to Professor Albert, 
who resected the alveolus inferior (nerve). One year and 
a half later the neuralgia reappeared, the pain recurring every 
two or three minutes, and lasting about twenty seconds. She 
came under his [G.'s] care, and he treated her on the lines 
indicated. The constipation was so obstinate in the first two 
weeks as to require frequent injections. In the second week 
some remission in intensity and duration of the neuralgic par- 
oxysms was noted. In the third week the patient suffered 

1 Prager medicin. Wochenschrift, 1886. 



THE CONSEQUENCES OF CONSTIPATION 179 

untold pains, and it was only the firm conviction that the neu- 
ralgia would disappear with the relief of the constipation that 
kept him from resorting to other remedies. After the third 
week marked improvement ; attacks less frequent, less intense ; 
patient could sleep part of the night ; could take more nourish- 
ment (sour milk and white bread). After four weeks attacks 
much more rare, of little intensity and brief duration, and after 
five weeks they disappeared altogether, and have not returned 
since. 

Of the trigeminal neuralgias it is mainly that form 
which is distinguished by intermittent paroxysms of pain, 
by typical convulsive movements of various muscles of 
the face, and by characteristic vasomotor disturbances, 
that is so related. 1 

D. Morbus Basedowii. 2 — Federn has described a cir- 
cumscribed atony of the gut, i.e. an atony in patches, 
alternating with patches of normal muscular force, which 
he regards as an etiological factor of Morbus Basedowii. 
His observations have not been corroborated. Indeed, 
his own statements seem so fanciful, and his cases are 
of so negative a character on the points to be demon- 
strated, that for the present the Scotch verdict of " not 
proven" must be rendered. 

As to the mode of production of the functional 
troubles described, it may be said that they are due to 
the systemic disturbances 3 that a prolonged and obstinate 
constipation may produce, and that in consequence thereof 
the general nutrition becomes much impaired, and the 
functional neuroses are developed. It is also more than 

1 Gussenbauer, loc. cit. 

2 Federn, Ueber partielle Dariiiatonie u. ihre Beziehung /.u Morbus Base- 
dowii u. anderen Krankheiten. Wiener Klinik, March-April, 1891. 

• s See p. 108. 



180 CONSTIPATION IN ADULTS 

likely that in some instances, especially in the case of the 
functional heart troubles, they are produced in a more 
direct way : the accumulated material sets np an irritation 
in the ganglionic cells, between the coats of the intestine, 1 
and this irritation is conveyed along the sympathetic 
system and also along the vagus nerve to the head or 
heart. 2 

An irritating, harassing cough without any pathological sub- 
stratum therefor in the bronchi or in the larynx, a reflex cough 
without any discoverable point of irritation either in the nose 
or in the throat, will sometimes be found to be intimately re- 
lated to the persistent constipation present, and that with the 
cure of the latter the former will disappear. 

An otalgia may be set up by irritating matters in the 
bowels. 3 

There are other neuralgias also due to constipation, but 
these may be produced in a merely mechanical way by 
the pressure of accumulated faeces upon the various nerve 
tracts in the abdominal cavity. 

E. Lumbo-abdominal Neuralgia. — Kisch 4 reports the 
case of a wealthy factory proprietor, aged fifty, who had 
suffered for years from pains shooting from the lumbar 
vertebra into the scrotum, paroxysmally, every few days, 
sometimes several times in one day. He had been treated 
in various ways without relief. He had obstinate con- 
stipation, and an examination of the rectum revealed 
haemorrhoids. By attention to these two abnormalities 
he was cured completely in several weeks. 

1 See Chapter I. 

2 See Illoway, " Cardiac Disturbances of Gastric Origin," New York Medi- 
cal Journal. April 24, 1897. 

3 Lauder Brunton, The Disorders of Digestion. 

4 Loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 181 

Overalgia. 

Sciatica A may be thus produced. 

* * * * * ' * * * * * * 

F. Insomnia. — Constipation is not infrequently the 
cause of sleeplessness, both in adults and children. A 
relief of the coprostasis is followed by a disappearance of 
the insomnia. 2 

In my own experience I have observed this insomnia in adults 
only when the coprostasis was attended with marked dyspeptic 
phenomena. 

*********** 

Psychoses. — Whether constipation may be an etiologi- 
cal factor in the production of mental ailments is a ques- 
tion that has not as yet been considered by alienists. 
Among the older writers various disturbances of the in- 
testinal canal are mentioned among the physical causes, 
but constipation is not named. Pritchard 3 describes 
among his etiological factors ' a condition of intestinal 
disturbance, in which constipation alternating with diar- 
rhoea is a prominent feature ; it is evidently, as there 
described, the constipation resulting from intestinal ca- 
tarrh, and he himself says it is not the constipation, but 
the underlying condition, that acts as the provoking 
cause. Esquirol 4 in his table of physical causes does not 
mention constipation, though he refers to it at another 
place, and calls attention to its importance in the treat- 
ment of the malady. Dr. Marcus Feyat r> in a monograph 

1 Henoch, Die Unterleibskrankh., Third Edition, 1863, p. 483. 

2 A. W. McFarlane, Insomnia and its Therapeutics, 1801. 

8 James Cowles Pritchard, M.D., F.R.S., A Treatise on Insanity, 183,"). 

4 E. Esquirol, Des Maladies Mentales, 1838. 

5 De la Constipation et des Phenomenes Toxiques quelle provoque. Etude 
de Pathologie Nerveux et Mentale, 1890. 



182 CONSTIPATION IN ADULTS 

on constipation and the toxic phenomena that it produces, 
with special reference to the nervous system, seems to 
hold that constipation is occasionally the direct cause of 
mental disease. 

Judging by analogy, from the well-established fact that 
hallucinations may be provoked by disturbances of the 
stomach, of the bowels, 1 it might, very properly, be as- 
sumed that constipation, when attended with marked 
indigestion, and the consequences thereof, — abundant de- 
velopment of flatus, distention of the bowels, sense of 
weight, oppression, colicky pahis, — - could per se, when 
long continued, cause a more decided perversion of the 
mental balance. In further support we may cite the con- 
dition of hypochondria that frequently attends obstinate 
coprostasis. 

*********** 

XVIII. Enlargement of the lingual tonsil, and therefore 
persistent and irritating cough. 2 

XIX. Diseases of the genital organs in young women. 3 
Constipation in young women when long continued may 
give rise to morbid processes in the genital organs. This 
occurs more particularly when there is great accumulation 
and marked induration of faeces. 

In the male it may give rise to pain in the spermatic 
cord 4 or in the testicle. 

Pain in the loins, in the groin. 

1 Dr. Marie Bra, Manuel de Maladies Mentales. Pritchard, loc. cit. 
Griesinger, Die Geisteskrankheiten. 

2 B. Robinson, Etiology and Treatment of Certain Kinds of Cough, Amer- 
ican Journal of the Medical Sciences, November, 1895. 

3 Dr. Eliza H. Root, in " Proceedings of the Illinois State Medical Society," 
1890, New York Medical Record, 1890. 

4 Charles Bell, loc. cit. Quoted also by Brunton, loc. cit. 



THE CONSEQUENCES OF CONSTIPATION 183 

XX. Chlorosis {chloro-ancemia), faecal anaemia. 1 

*********** 

XXI. Constant Noises in the Abdomen (borborygmi). — 
A not inconsiderable number of persons are troubled with 
continual noises in the abdomen. These borborygmi are 
more or less loud, and in some cases can be heard at quite 
a distance, three to four feet, from the person. They are 
incessant ; there is a constant rumbling and growling and 
squeaking in the abdomen, with but very brief intervals 
of quiet. This condition is a source of great annoyance 
to the persons so troubled, and not infrequently to their 
immediate surroundings. It has in some instances com- 
pelled absolute withdrawal from society. 

According to my own observation, it is chiefly women 
who are thus troubled, and of these again mainly such as 
have confining occupations, — seamstresses, shop-girls, book- 
keepers, housewives who are such home bodies that they 
will not take sufficient outdoor exercise. I have found 
them all to be constipated, and even those who claimed 
more or less regularity of action for their bowels were 
proven to be costive by an inspection of then faecal dis- 
charges. 

In consequence of the constipation the flatus developed 
is retained and accumulates, and chiefly in the small intes- 
tines. It excites a local peristalsis there, is driven from 
one section of the loop to another, from one loop to 
another, and thus the noise is produced. In the case of 
a young shop-girl under my care, in whom the noises were 
very loud, the hand laid upon the abdomen could detect 

1 British Medical Journal, November 19, 1S87. New York Medical Record, 
1887 (latter half). Osier, Practice of Medicine, 1802. 



184 CONSTIPATION IN ADULTS 

very distinctly the movements of the small bowels under- 
neath it; sometimes the peristaltic wave could be seen 
upon the abdominal wall. 

Many of these persons are much troubled with colics. 

A cure of the constipation relieves the patient of the 
noises. 



SECTION II. — TREATMENT 

CHAPTER XV 

TREATMENT 

Treatment of Constipation due to Atony of the Intestine. 

From what has been said in the preceding chapters it 
can be readily seen that habitual constipation is not the 
trivial matter it is held to be by most people, but that 
it is a derangement which^ by reason of the grave evils 
that may arise therefrom, should be remedied as soon 
as possible, and therefore deserves the earnest considera- 
tion of all whose function it is to study and treat disease. 

Constipation dependent upon an atonic condition of the 
intestinal muscular apparatus being, as already set forth, 
the most frequent, the most common form that presents 
itself to us, the consideration of its relief must naturally 
take the first place. 

The indications for treatment are here, as in other mor- 
bid conditions, twofold. 

I. The removal of the cause — remotns causa tollitnr 

effectus. 

II. The restoration of the bowel to its pristine vigor. 

I. The first indication we will meet by instructing our 
patients in the following rules, and insisting strenuously 
upon their observance. These rules have the consensus 

185 



186 CONSTIPATION IN ADULTS 

of the whole profession, and then rationale is already 
explained in the chapter on the etiology of habitual 
constipation. 

1. Go to the closet once a day, call or no call. 

Ever since Trousseau 1 one of the principal features in 
the treatment of constipation has been the recommen- 
dation that the individual go to the water-closet every 
day and at the same hour ; the time most favored being 
that after breakfast. On the last part of the recommen- 
dation I deviate from the usual practice. I instruct my 
patient that he must go to the closet once every day, 
shortly after a meal, but at such period of the day at 
which he finds it most convenient, at which he can take 
ample time for the business before him, whether that be 
after breakfast one day, after lunch or dinner the next, or 
after dinner or supper on still another day. I have done 
this and still do this for the reason that I have found in a 
number of instances that patients cannot comply abso- 
lutely with the rule of the French clinician, and a neglect 
of it on one day is at once followed by a relapse of the 
constipation. This is the age of irregularity of habit ; 
one retires early one evening, and rises with the lark the 
next morning, with ample time for all the duties before 
him ; another night we are kept up to the wee sma' hours, 
and rise in the morning with barely sufficient time to 
dress. Or again, we may be very much occupied at a 
certain hour one day, and may have nothing to do at the 
same hour on the following day. I prefer, therefore, 
that the patient shall go to stool at the time of day at 
which it is most convenient for him or her, and have 

1 " Lectures on Clinical Medicine," Engl. TV., Vol. II., p. 492, Phila. Edition. 



TREATMENT 187 

found that the bowels accustom themselves to respond to 
such irregularly regular solicitation as regularly as in the 
cases of a fixed and unchangeable period. 

2. Do not leave the call of nature unheeded ; respond 
promptly or with as little delay as possible — before the 
call dies away. 

3. Do not read a book or paper or occupy your mind 
whilst engaged in the performance of your duty in the 
sequestered realm of cloacina. Keep your mind fully 
upon the business before you. 

4. Eat and drink properly. 

5. Take a sufficient amount of exercise. 

6. Do not overtax your brain ; it is a delicate organ 
and resents terribly all abuse. He who would have a 
healthy body must keep a healthy mind. Give your 
brain diversion and your body sufficient exercise. 

7. Do not take any purgatives ; they are the enemies 
of a regular habit. They promote constipation. 

8. Have your bedroom well ventilated. 

Diet. — The importance of a well-regulated diet for the 
normal performance of physiological function on the part 
of the bowels cannot be overestimated. It has already 
been shown that fsecal matter is made up in greater part 
of the indigestible residue of the alimentary matters. 
A microscopical examination of fseces shows an abundant 
quantity of cellulose or vegetable wood-fibre. It is very 
evident therefore that a proper diet is one that with 
sufficient nutritive material furnishes the necessary quan- 
tity of residual matter to incite the bowels to action. 
With persons inclined to constipation or already suffering 
therefrom, such articles of food as contain a large per- 



188 CONSTIPATION IN ADULTS 

centage of indigestible fibre should occupy a prominent 
place in the diet list ; viz. 

Rye, as Bread. — Rye bread has the advantage that it retains 
its humidity and at the same time preserves its flavor. " When 
made of flour not too finely bolted, rye bread is suited to 
certain forms of dyspepsia with costiveness, and the subjects 
of which are of a sanguine temperament." Rye meal boiled 
in water (rye mush) is very useful in cases of habitual costive- 
ness, taken with molasses ; or in cases less obstinate, eaten 
with milk. 1 

Oats. — " A diet of oats has the credit of tending to keep the 
bowels open ; and I have seen it apparently have this effect 
in several instances of habitual constipation when taken at 
breakfast in the form of porridge." 2 

I recommend oatmeal regularly, except in cases where 
a catarrhal condition of the stomach or bowels exists. I 
direct that it be well boiled in a double pot, a steamer, 
and be eaten with syrup (New Orleans, in place of sugar), 
about two tablespoonfuls, and milk. 

I have generally been well satisfied with its action. 

Where it causes a sort of a diarrhoea, running through 
the intestinal canal with great rapidity and undigested, 
it must, of course, be stopped, as, if continued, it would 
certainly prove detrimental. When this is due to the oat- 
meal not being properly cooked, as is sometimes the case, 
this only need be remedied. 

Cracked Wheat. — It can be used in the form of mush or as 
the more constituent element of a soup. 3 It is excellent as 
bread, Graham bread, Graham crackers, etc. 

1 Pereira, Food and Diet, Phila. Edition. 

2 Dr. Christison, Dispensatory. Pereira, loc. cit. 

3 Boas, I., Di'at u. Wegweiser fur Darmleidende, Berlin, 1890. 



TREATMENT 189 

Hominy, Cabbage, Cauliflower, Asparagus, Spinach, Dandelion, 
Lettuce, the Tops of Beets, Greens. — " The green matter of 
plants is in general little acted on by the stomach of the 
higher animals. . . . The green matter of plants contributes, 
as above mentioned, to the action of the bowels by its excre- 
mental properties." 1 

Carrots, Turnips, Parsnips, Green Beans, Green Peas, Cucum- 
bers, Fruits. — The value as a stimulus to peristaltic action of 
some of these articles may be enhanced by the method of preparing 
them for use ; as Sauerkraut, which can be eaten raw or cooked, 
or the various Vegetable Salads prepared with oil and vinegar. 

Other articles of diet which, though their percentage of 
residual material is small, even minute, are nevertheless 
of importance as tending either to excite peristalsis or to 
keep the faeces soft and* pasty, are : Butter, Buttermilk, 
Cottage Cheese, Fats, Oils (vegetable), Vinegar, Molasses 
or Syrup, Salt. 

All such articles as have a tendency to constipate must 
be prohibited. These are more especially : 

Rice. — " Indeed it is generally believed to possess a binding 
or constipating quality ; and in consequence is frequently pre- 
scribed by medical men as a light, digestible, and uninjurious 
article of food in diarrhoea and dysentery." 2 

Barley, Sago, Potatoes (mashed), Dried Peas, Dried Beans 
(particularly in the form of mush or pap). They are apt to 
cause flatulence and thereby are still further detrimental. 

Cheese, other than that mentioned above. 

Cocoa, Green Tea, 3 Nuts, Blackberries, Bilberries, 
Mustard, Pepper. 

1 Prout, On the Nature and Treatment of Stomach and Urinary Diseases, 
1840. Pereira, loc. cit. 

2 Pereira, loc. cit. 

3 Contains a considerable amount of tannin, more than black tea. Pe- 
reira, loc. cit. The ordinary article is said to be very much adulterated ami 
dyed with verdigris. 



190 CONSTIPATION IN ADULTS 

" Man is a cooking animal," a great philosopher has 
said. All his food must first be prepared before it is fit 
for consumption. The essentially American method of 
cooking food, namely frying, must be absolutely prohib- 
ited as unsuitable for the constipated. The food thus 
prepared is positively deleterious. It is a potent factor 
in the production of dyspepsia and all dyspepsias tend 
to constipation. Moreover, constipation is attended with 
more or less of dyspepsia, and the aggravation of this lat- 
ter by the fried food will make the patient very miserable. 

Diet List for Constipated Persons. 

Soups : meat broths ; vegetable soups ; oatmeal soup ; cracked 
wheat soup. 

All soups must be thin. 

Fish : fresh only, of all kinds and prepared in any way. 
Fried fish and fish prepared with mustard or peppers excepted. 

Meats : fresh only, of all kinds and prepared in any way 
except by frying. 

Eggs : except fried. 

Miscellaneous : Cottage Cheese, Butter, Buttermilk. 

Bread and Farinaceous Articles : Graham bread, Graham 
crackers, brown bread, rye bread. All bread must be cold. 
Oatmeal crackers, oatmeal mush, hominy, cracked wheat, rye 
mush. 

Macaroni, vermicelli, in small quantity and to be eaten with 
fruit-jelly, or syrup (molasses). 

Vegetables : cabbage, sauerkraut, greens, cauliflower, aspara- 
gus, spinach, beet-root tops, dandelion (boiled), onions (green), 
carrots, turnips, turnip-cabbage, onions (boiled). Potatoes 
very sparingly and only boiled in their jackets or baked. 
Radishes in season. Rhubarb plant (syrup can be used in the 
preparation thereof in place of sugar). 

Salads, prepared with vinegar and oil or with vinegar alone : 
Lettuce, dandelion, beets, cucumbers, Bermuda onions. 



TREATMENT 191 

Desserts : raw fruit ; stewed fruits ; baked apples ; light 
puddings, bread or fruit ; ice cream ; ices. 

Tea or Coffee. When coffee is taken, it should be good, not 
dish-water. It should be allowed only for breakfast. Where 
the habit has been established, a small demi-tasse may be 
allowed after dinner. 

The tea or coffee must be drunk fairly cool. Exception 
can be made for winter mornings. 

Tea (preferably black tea, though even this is said to 
undergo adulteration and dyeing), when taken for breakfast, 
may be of fair strength ; but not more than one cup to be 
allowed. When taken after dinner, it should be weak. Where 
cheaper grades of tea are used (from necessity), it is well to 
instruct the patient that the first water poured on the tea 
should be decanted off and thrown away ; thus a great deal 
of the noxious matters, if any exist therein, and some of the 
tannin constituent is gotten rid of. 

The tea, like the coffee, should be drunk fairly cool, except on 
winter mornings when a certain amount of heat may be allowed 
therein. 

Special Dietary Directions. — Stewed fruit should con- 
stitute one of the regular dishes both of the morning and 
of the evening meal. It should be eaten freely ; in much 
larger quantity than is customary — a good, large plate- 
ful at each of the meals named. Of excellent service 
are stewed fresh apples, stewed fresh pears, stewed fresh 
plums, and, when out of season, these fruits dried. Two 
or three varieties may be boiled together, as apples and 
pears or apples and plums, plums or prunes and figs. 
Tamarinds, where they can be obtained, are also useful. 
Dried prunes or plums should be cut up before boiling. 
Cooked whole and eaten that way, they tend to consti- 
pate after a while. Dried peaches and canned peaches 
have a tendency to constipate, and should not be taken 



192 CONSTIPATION IN ADULTS 

therefore in any quantity. When raw fruit is eaten in 
the morning, — and all juicy and tart fruits are good, — 
the stewed dish can of course be omitted. Baked apples 
are very effective with many people. They can be eaten 
two or three times a day. 1 

Boas directs his patients to take a tablespoonful of 
sugar of milk in a glass of milk three times a day, be- 
lieving that it possesses laxative properties. I prefer to 
prescribe molasses or syrup to be taken with mush or 
macaroni or to be eaten with bread after the fashion 
of the children of the South. 

A glass of buttermilk may be taken twice a day as a 
sort of lunch between the morning and the noon meal, 
about 10 a.m., and between the noon and the evening 
meal, about 4 p.m. 

Patients must eat moderately ; gross eating tends to 
constipation. 

Drink. — The importance of water to the animal econ- 
omy is well known and need not be dwelt upon here. 
What concerns us to know, is the fact that cool water 
excites intestinal peristalsis and energizes intestinal action, 
whilst at the same time it dilutes the intestinal contents, 
which greatly facilitates their propulsion. The effect is 
undoubtedly due to the exciting action of the cold, and 
is very well and clearly demonstrated by the violent 
peristalsis or colic excited when the temperature of the 
drink taken is too low, and by the universal experience 
that warm drinks allay peristalsis, even though they 
do dilute the intestinal contents. 2 Cool, fresh water 

1 Pereira, loc. cit. 

2 Handbuch der Allgemeinen Therapie (Ziemssen), Band II., Theil I. 
Leichtenstern Allgm. Balneotherapy p. 296. 



TREATMENT 193 

should therefore form the staple drink of the constipated 
or those so inclined. In addition we should direct them 
to take a drink of cool, fresh water the first thing on ris- 
ing in the morning or before the breakfast is eaten and just 
before retiring at night. 

Soda water with tart fruit syrups may be permitted. 
-So also the class of mineral waters known as table 
waters. 

Root beer, a fermented decoction of sassafras and sarsa- 
parilla (the decoction put up in bottles and sold everywhere, 
sold at soda stands by the glass), and siveet cider are 
allowed ; can even be recommended as beneficial. 

To be avoided are the artificial seltzer waters which are 
taken by many people in lieu of plain water. The habit 
•of drinking hot water on arising in the morning is to be 
condemned. Alcoholic liquors, especially red wines, bran- 
dies, whiskies, gins, liqueurs, are to be prohibited. 

Where, in consequence of established habit or for some 
•other cause, some form of alcoholic stimulant is required, 
we may permit a glass of light, tart, white wine, as the 
lighter Rhine wines and our native wines, Catawba, Dela- 
ware, California Riesling, or a light beer. 

Exercise. — The necessity of exercise, of muscular activ- 
ity, in the open air to the well-being of the human 
economy is well known ; its importance for the proper 
performance of physiological function on the part of the 
intestine has been already set forth. 

Exercise may be taken in various ways : Walking. 
horseback riding, sivimming, roiving, riding in a vehicle. 

Walking is one of the best forms of exercise ; can be 
indulged in at any time ; costs nothing and is therefore 



194 CONSTIPATION IN ADULTS 

within the reach of all. It answers all that can be de- 
manded of exercise ; viz. it sets into activity all the 
muscles of the body, stimulates respiration and thereby 
the inhalation of oxygen, stimulates and makes more 
energetic the heart's action, thus increasing the rapidity 
of the blood current, arterializing the blood more fully 
and distributing greater quantities of oxygen to the 
tissues. 

Investigations upon the circulation have shown that 
the negative pressure in the thorax during inspiration has 
a most powerful aspirating action upon the returning 
venous blood current, and this is rendered still more 
powerful by increase of frequency and depth of inspira- 
tion. 1 Braune has demonstrated that the fasciae around 
Poupart's ligament are so arranged that movement in the 
hip joint produces an aspiration of the blood in the 
crural vein and hastens its onflow into the inferior vena 
cava, 2 and naturally the more extensive and the more 
frequent the motion, the stronger the aspiration. A simi- 
lar arrangement, though not so powerful in effect as 
either of the others, has been claimed for the fascia and 
muscles beneath the clavicle. 3 

Walking, which makes all these factors more effective, 
is thus of especial benefit to the constipated. The circu- 
lation in the intestinal tract being greatly increased in 
activity, a greater amount of oxygen is carried into all its 

1 Bush, Allgemeine Orthop'adie, Gymnastik u. Massage. Handbuch der 
Allgemeinen Therapie, Band II., Theil II. 

2 Die Oberschenkel Vene in anatomischer u. klinischer Beziehung, Leip- 
zig, 1873. Handbuch der Allgemeinen Therapie, Band II., Theil II. 

3 Herzog, Beitrage zum Mechanismus der Blutbewegung, etc. Deutsche 
Zeitschrift fur Chirurgie, Bd. 16, p. 1, 1881. Handbuch der Allgemeinen 
Therapie, loc. cit. 



TREATMENT 195 

tissues, and oxygen, as has been shown by Nasse, stimu- 
lates intestinal peristalsis. 1 

The lymphatic currents are also quickened by these 
same agencies and necessarily the lacteals and lymphatic 
spaces are emptied with greater rapidity ; absorption is 
hastened and the whole digestive process rendered more 
energetic, more perfect, and the volume of gases, flatus, 
developed is greatly diminished. 

In this way also greater energy is imparted to the 
muscular structures and peristalsis becomes more perfect. 2 

It is true that to be beneficial a certain amount of 
ground should be covered, and it is likewise true that 
most of our patients, especially in this country, are but 
poor walkers. This is, however, a difficulty readily over- 
come. Walking is a matter of education. This is clearly 
shown by the rapidity with which army recruits accustom 
themselves to great distances without experiencing any 
ill-effect therefrom. 3 The person who feels fatigued after 
a walk of five blocks to-day will, with daily practice, 
accomplish ten or fifteen blocks within a week. Thus 
our patients must be taught to walk until they can take 
their mile or two or their spin for an hour without feeling 
at all fatigued. 

I have also found that very often, especially in the case 
of ladies, the difficulty in walking lies in the shoe ; a very 
thin sole that allows all the inequalities of the pavement, 
the hardness of the rock, and the sharpness of the cobble- 
stone to be readily felt through it, brings on fatigue very 

1 Nasse, Zur Physiologie d. Darmbewegung, 1800. Foster, M., Physiology. 

2 Foster, M., Physiology. 

3 Dr. L. Blondlot, Manuel d. Gymnastique, Paris, 1877. 



196 CONSTIPATION IN ADULTS 

rapidly. A good stout sole, that provides for the foot a 
very elastic superpavement as it were, is a requisite sine 
qua non for this the most healthful and most inexpensive 
of exercises. 

The following rules may be given to the patient for his 
guidance : 

Do not walk immediately after a hearty meal ; wait till 
the digestive process is well on its way, an hour and a half 
after a breakfast, two or three hours after a dinner. 

Walk at a fairly brisk gait (except in hot weather). Too 
slow or too fast fatigue quickly. 

Where convenient, walk in a park or in the open country. 

Take your walk in the cool of the day in the warm months, 
and in the warmest part of the day in the cold months, if 
you can so arrange your time. 

Never walk till you are tired. Keep this side of the 
limits of fatigue. 

Do not eat heartily immediately upon your return from a 
long walk ; if you need something to refresh you, a cup of 
hot milk, a glass of buttermilk, a cup of tea, a cup of beef 
tea (made with the extract), a small glass of beer with a bit 
of bread, or a glass of wine and a wafer or bit of bread for 
persons who are accustomed to these, will fulfil all the 
requirements ; it will refresh you and not impair your 
appetite ; in fact, will improve it. 

One of the immediate and direct benefits of this exer- 
cise to the constipated is the ease and facility with which 
accumulations of flatus, a source of great annoyance, fre- 
quently of suffering, and an obstacle to recovery (by reason 
of their keeping the bowels distended), are discharged. 

Swimming is also an excellent form of exercise, espe- 







TREATMENT 197 

cially adapted for the summer, for climates where walking 
is too fatiguing at that season of the year. It has in 
addition the advantage of the stimulating effect of the 
cold water upon the abdominal parietes, and through them 
upon the abdominal viscera, especially upon the intestines. 

Horseback Riding. — When for any reason persons will 
not or cannot walk, horseback riding will very well take 
its place. The shaking and jarring of the bowels and 
abdominal viscera with every movement of the horse 
renders it especially suitable to the constipated. More- 
over, the rapid carrying of the body through space, and 
the necessary muscular effort to maintain the seat, to 
maintain the equilibrium, make it, in a way, even more 
energetic than walking. A trotting horse should be had 
for the exercise. 

Rowing is not as good an exercise for the purposes of 
this derangement as either of the three before mentioned. 

Riding in a Vehicle. — A carriage or buggy or street 
car is of no benefit to the constipated. The only vehicles, 
if vehicles there must be, that are in any way serviceable 
are the lumbering omnibus that travels over a road paved 
with cobblestones and the springless cart, which provide 
shocks and jars and shakings-up innumerable for the body. 
For torpid livers, the springless cart, a long ride every 
day along a country road, or even the top of an omnibus 
will do good service. I have seen marked benefit derived 
from them in chronic hepatic congestions. 

Bicycle Riding as it is usually done, with the body well 
bent forward and all the thoracic and abdominal viscera 
compressed, T consider worse than useless for the con- 
stipated. 



198 CONSTIPATION IN ADULTS 

There are several important points connected with the 
question of exercise which it is well to bear in mind. 

1. All exercise to be of the greatest benefit must be 
taken in the open air. Even when patients say that they 
have sufficient work and exercise at home, and that it is 
rest they want rather than exercise, we must nevertheless 
insist upon their taking some exercise in the open air, and 
even if by so doing they must neglect some of their duties 
at home. It has been with me a matter of frequent obser- 
vation in persons, especially housewives, who were kept 
very much confined at home that, despite physical work 
which afforded sufficient muscular exercise, the appetite 
would fail and the bowels would become costive, and this 
even in good homes. It was because of insufficient oxy- 
genation ; because of the lack of that superabundance of 
oxygen which we take in in great draughts, and scatter 
throughout all our tissues when we exercise in the open 
air. A day out in the country, even a long walk through 
the city, through the park, effected at once a marked 
change for the better in the persons above referred to. 
It is the air bath that we require as much as anything else. 

From ample clinical observation I have come to conclude 
that, under normal conditions at least, the position of Nasse, 1 
that O incites to peristalsis, is correct, and that C0 2 allays 
peristalsis. I am fortified in this conclusion by the experience 
of Birch, 2 who, in cases of obstinate constipation, saw almost 
immediate effects from the inhalation of O, and by the experi- 
ence of Dr. Ach. Rose, 3 who claims remarkable results from 

1 Loc. cit. 

2 Constipated Bowels, the Various Causes, etc., Fhila. Edition, 1868. 

3 "Therapeutic Effects of Carbonic Acid," etc., New York Medical Jour- 
nal, March 9, 1895. 



TREATMENT 199 

the local application of C0 2 in all intestinal complaints attended 
with great irritability and much pain. 

2. All exercise must be kept this side of fatigue. The 
amount of exercise to be taken must be regulated by 
the vigor of the patient and never allowed to go to the 
point of exhaustion. The patient must feel refreshed, 
invigorated, and his appetite must have been aroused; 
then will he have benefited by the exercise. 

3. It must never be taken upon a full meal, for with 
the task of digestion before it the system is unequal 
to the effort. As to the proper time, that has been 
indicated in the rules for walking. 

4. Human nature accommodates itself very rapidly to 
changes of conditions and circumstances, and for this 
reason a variation in the form of exercise is desirable 
and advantageous. 

Furthermore, the habits and occupation of the patient 
must be taken into consideration when ordering exercise. 
Thus we would not prescribe walking for a letter carrier 
or riding for an omnibus driver. A change from the 
usual, from what their nature has become accustomed 
to, is what is wanted and what we must prescribe. 

There is one form of exercise which is not generally 
referred to under this head, as it is more in the nature 
of work, mention of which must not be neglected, and 
that is gardening or farm work. In a few cases of severe 
indigestion and obstinate constipation, alone or combined, 
where the opportunity offered for taking this form of 
exercise, the patients derived the greatest benefit there- 
from ; in fact, their rapid recovery was in a great measure 
due thereto. 



200 CONSTIPATION IN ADULTS 

Other etiological factors must be met according to 
their nature. 

Adulterations. — Where adulteration of food or drink 
are the etiological factors as already described, we must 
see to it that such impure articles are banished from the 
dietary of our patient. 

The breads here recommended, rye bread or graham 
bread, are generally free from adulteration ; it is only the 
very fine white flours that are liable thereto. 1 

Baking powders : only such as contain no alum must be 
used. Where we have reason to suspect that the water 
is impregnated with toxic agents, we must either abstain 
from it in toto, confining ourselves to the use of the 
mineral table waters, or we must see to it that it is well 
filtered. 

Hard water that disagrees should likewise be filtered or 
distilled, or, if a change is absolutely necessary, either the 
mineral table waters may be substituted, or, where these 
cannot be had for any reason, filtered rain water can very 
well take their place. 

Relaxation of the Abdominal Walls, or its extreme degree, 
Pendulous Belly. — This condition, which is most frequently 
met with in women, and is usually the result of neglect of 
the proper toilet after parturition, occurs occasionally in 
men (as also in women) as a result of loss in the pannicu- 
lus adiposus. Where the relaxation is not very great, much 
may be done to restore the tone of the abdominal parietes 
by measures to be described farther on. For the pendu- 
lous belly nothing can be done to restore it to its former 
condition. In both conditions, however, the fault can be 

1 Birch, loc. cit. 



TREATMENT 



201 



at once remedied in a measure, and greater comfort 
afforded the patient by the application of a well-fitting 
abdominal bandage or belt. 1 Excellent ones are made of 
this shape, and are for sale with instrument makers. 




Rosenheim's Bandage. 





Corset-shaped Abdominal 

Bandage. 
Laced over the hips. (De- 
signed by the author.) 
a, Half-inch binding put 
on tightly to brace lower 
part of bandage. 



The same open. B, braces. 



Where the item of expense is an 
important factor, a plain roller band 
about four inches wide can be used. 
It is rolled around one thigh first 
and fastened, and then swung around the lower part of 
the abdomen, and then upwards until it has just passed 
the navel. Where there is a tendency to slip, the whole 
bandage can be held up by two bands thrown across the 
shoulders like suspenders. 

1 These belts and bandages are also suitable for the casos of Entero- 
and Splanchnoptosis. 



202 



CONSTIPATION IN ADULTS 



A cheap bandage or belt can be made of canvas and of 
the shape shown in the cut. It answers very well. 




The end pieces are made sufficiently narrow so that they can be crossed on the 
back and brought forward and buttoned in front, as shown in the cut. 



CHAPTER XVI 

TREATMENT OF CONSTIPATION DUE TO ATONY {Continued) 

Second Indication. — The restoration of the bowels to 
their pristine vigor. 

It is to-day a fact admitted by all, by the most eminent 
clinicians, 1 that a restoration of normal tone to the bow- 
els can be best achieved, and in the great majority of the 
cases achieved only, by means of the mechanical methods 
of treatment. These, with which every practising physi- 
cian needs familiarize himself, are : 

I. Massage. 
II. Hydrotherapy. 
III. Electricity. 

I. Massage 

That massage is of the greatest efficacy in the treat- 
ment of constipation is now generally admitted. Professor 
Nothnagel 2 says that it takes front rank in the treatment 
of this derangement. Le Marinel 3 has published but lately 
a long list of cases successfully treated. In my own 
hands it has likewise proved of the greatest efficacy, and 
has given me results as I have never obtained with me- 

1 (riisse.nbauer, loc. cit. Nothnagel, Wiener mediz. Presse, 1890. 

2 Loc. cit. 

3 Annales de la Societe Koyale des Sciences Medicales et Naturelles de 
Bruxelles, Fascic. 1. and IT., 1890. 

20:\ 



204 CONSTIPATION IN ADULTS 

dicinal agents, no matter of what nature or how admin- 
istered. 

Furthermore, the results and benefits are so striking 
and manifest themselves so early that the patients them- 
selves gain confidence in the treatment, and do all in 
their power, by the observation of the rules and regu- 
lations laid down for them, to carry it to a successful 
issue, whilst it was just the reverse with the medicinal 
treatment. The patients, seeing no results, soon grew 
tired of rules and regulations, relapsed into their former 
modes of life and vicious habits, and thus destroyed what- 
ever chance of success it may have had. 

Physiological Action. — It is not to the purpose of this 
book to go into a detailed account of the modus operandi 
upon the tissues, of the physiological action, of massage; 
it will suffice here to say that : 

It has been demonstrated by Mosengeil, 1 and these 
experiences and results have been confirmed by Salis, by 
Genersich, 2 by Paschutin, 3 by Keibmayer, 4 and by still 
others, that massage stimulates absorption, and that 
under its influence even foreign bodies that had been 
introduced subcutaneously could be made to penetrate 
into the depths of the perivascular spaces. Clinically it 
has been shown that inflammatory exudations, even when 
old and organized, can be broken down and liquefied and 

1 " Ueber Massage, deren Technik, Wirkung," etc., Verhandl. d. Deutsch. 
Gesellschaft fiir Chirurgie, 4th Congress, 1879. 

- "Die Aufnahme der Lymphe durch die Sehnen," etc., Arbeiten aus d. 
Phys. Anstalt zu Leipzig, 1870. 

3 "Ueber die Absonderung d. Lymphe im Arm des Hundes," Ibid. 1872. 

4 Die Massage u. ihre Verwerthung in den verschiedenen Disciplinen 
der Medicin, Vienna. 1881. 



TREATMENT OF CONSTIPATION DUE TO ATONY 205 

reabsorbed, and serous effusions be made to disappear in 
brief time. 1 

It stimulates the circulation. The veins pressed upon 
in the course of the manipulations are more quickly emp- 
tied ; the venous column in advance is forced onward, 
the arterial circulation in the immediate locality is has- 
tened, and then the whole blood current is considerably 
quickened. 

At the same time the lymphatic vessels and spaces 
being acted upon in a similar manner, these streams are 
likewise quickened, and thus nutrition and metabolic 
metamorphosis hastened. It is by this quickening of the 
blood and lymph currents that the greater rapidity of 
absorption finds its explanation. 2 

It acts upon the muscle as a whole, and upon the mus- 
cular fibres individually, in which it provokes fibrillary 
contractions. This contraction, for the production of 
which the mechanical action alone suffices, is increased 
both in amplitude and magnitude by the greater activity 
of the circulation, consequently greater oxygenation, and 
therefore increased assimilation and more rapid discharge 
of waste. 3 

The ganglionic nerves in the parts massaged are 
stimulated . and exalted in their functioning power, and 
this exaltation is reflected back to the nervous system 
in general, and greater activity in the physiological 

1 Bush, Handbuch der Allgemeinen Therapie (Ziemssen), Bd. II., Theil 1 1 . 

2 Bush, loc. cit. Le Marinel, loc cit. Reibmayer, Die Technik der 
Massage. 

3 Zabludowski, Ueber die physiologische Bedeutung d. Massage. Cen~ 
tralblatt f. d. medic. Wissenschaftetij No. 14, 1883. Dr. Georges Homo. Le 
Massage, Paris, 1894. 



206 CONSTIPATION IN ADULTS 

functioning of all the various organs over which it pre- 
sides results. 1 

Technique. — Massage, whether it be derived from the 
Greek ixavcreLv (massein), to rub, or from the Arabic mass, 
to press gently, 2 means in reality the manipulation of a 
body by the hands of a manipulator, and the carrying out 
thereon of various well-devised movements. The move- 
ments may be divided into four great groups, with more 
or less numerous subdivisions : 3 

(a) Effleurage {Stroking). — Is made in diverse ways 
according to the locality and the extent of region to be 
treated. It can be made with the hand or with two 
hands, with the tips of the fingers or with the thumb 
alone. When the hand is used, it is so applied as to fit 
snugly to the configuration of that part of the body to 
be treated, the greatest pressure being exercised upon the 
side where the great vessels, lymphatics, and veins are 
found. Whichever way this manipulation is made, it is 
always a go-and-come movement, more or less rapid, with 
the pressure always made centripetally, in the direction 
of the heart. No pressure is made on the return to the 
point of beginning. The location of the lesion, whether 
superficial or deep-seated, determines the amount of the 
pressure to be made. The deeper seated the lesion, the 
greater the pressure to be exercised. 

The aim of effleurage is to force back any superfluous 
liquids in the part massaged and to activate the circula- 
tion in general, both sanguine and lymphatic. 

1 Technic of Ling's System of Manual Treatment, etc., by Arvid Kellgren. 
See chapter " Nerve Vibration." Reibmayer, loc. cit. Schreiber, Praktische 
Anleitung zur Behandlung durch Massage. 2 Bush, loc. cit. 

3 Reibmayer, Die Technik der Massage. Berne, loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 207 

(b) Frictions (Massage a frictions, Reibungen, rubbing). 
-These, which are always vigorous movements, are 




Effleurage with the Tips of the Fingers. (Reibmayer.) 

made in a circular direction with the whole hand, more 
especially with the tips of the fingers or of the thumb. 
This movement is always supplemented with strong 




Frictions with the Thumb. (Ostrom.) 

centripetal stroking, made with the same or with the 
other hand. 

Frictions can be made in any direction. The purpose 



208 



CONSTIPATION IN ADULTS 



of the movement is to break up any pathological products 
and to scatter them in the surrounding healthy tissue. 

(c) Petrissage (Druecken, kneading, pressing, rolling). 
— This can be done with the thumb or with both thumbs, 
or with the thumb and index finger or thumb and four 
fingers, with the palms of the two hands. When petris- 
sage is intended more as a pressing movement, and is made 
with the thumb or thumbs alone, it differs from frictions 
in this, that the circle described in making the movement 




Petrissage with the Tips of the Thumbs. (Ostrom.) 

is very much smaller, the sphere of action being more 
limited. It finds its special application there . where a 
particular tissue or organ, as a certain muscle in the ex- 
tremities, in the abdomen, a special section of the bowel, 
can be picked up and out from the surrounding structures 
and rolled or kneaded or pressed between the palms of 
the hands, or between the thumbs or thumb and four 
fingers. 

In carrying out this manoeuvre, we must avoid the 




TREATMENT OF CONSTIPATION DUE TO ATONY 209 

localities especially rich in blood-vessels, nerves, and 
lymphatics, as Scarpa's triangle or the axilla. 

Its effect is like that of friction, though greater. 

(d) Tapotement (Percussion). — The group richest in 
subdivisions. The principal, only, of these subdivisions, 
those which are more particularly required for our pur- 
poses, will be named here. 

Clapping, with the flat of the hand ; with the dorsum of 
the hand ; with the dorsal sur- 
faces of the last phalanges. 

Hacking (hachure), with the 
ulnar borders of the hand. 

Punctating, with the points 
of the fingers. 

Beating, with the clenched 

hand. Petrissage of a Muscle be- 

m . ,, TWEEN THE THUMB AND INDEX FlN- 

Ihese movements are all GER . (#.) 
made from the wrist. 

Shaking, concussing (Erschutterung). The part to be 
treated is grasped with the hand or with two hands, and 
rapid movements made in a horizontal or transverse 
direction. 

Vibration (oscillation), of two kinds, strong and light. 
The strong vibration (the shaking of Kellgren) is exe- 
cuted, according to Kellgren, as follows : " The part of 
the hand which during the manipulation of shaking 
comes in contact with the patient's body, is the distal 
phalanx of one or more fingers, and it or they should be 
applied softly and not pointedly. 

" The movement starts from the elbow joint of the 
manipulator, where there is slight flexion and extension. 



210 CONSTIPATION IN ADULTS 

Between it and the ultimate phalanges of the fingers, the 
bones of the forearm, wrist, and hand, with their inter- 
mediate joints, act, so to speak, as links in a chain, 
through which a wavelike motion is sent and propagated 
to the part worked upon. 

" The movement of the hand is very quick. The joints 
must not be kept stiff, but just so far extended that elas- 
ticity is permitted and not hindered." 

This manipulation is said to quicken resorption, to 
stimulate, and to invigorate. It is applied chiefly to the 
various organs, larynx, eyes, stomach, etc. 

The mild vibrations, the vibrations of authors, are thus 
described by Kellgren : " The vibrations are, one might 
say, only mild shakings. The whole or part of the palmar 
surface of the hand or fingers is used in this kind of 
manipulation. Here, as in the shaking, there is flexion 
and extension at the elbow, but they are much smaller. 
The movements in the loose wrist joint are abduction and 
adduction (i.e. radial and ulnar flexion) of the hand, which 
lies immovable so far as the part of the surface of the 
body on which it rests is concerned. Through the quick 
succession of the individual movements, the vibrations are 
produced. 

" The straining of the muscles in the operator's arm 
ought to be so slight as to be scarcely perceptible to any 
one who has his hands over them. On no account are 
the vibrations to be produced by the continued strong 
contractions of the muscles of the shoulder, arm, and 
hand." * 

The masseur usually anoints his fingers with some oily 

1 Kellgren, loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 211 

substance, — fats, olive oil, cold cream ; vaseline is now 
generally used for this purpose. 

Abdominal Massage. — This should be made upon the 
naked abdomen. It can never be so effective when made 
over a covering cloth, as can be readily understood. All 
impediments to the circulation, as corsets, must be re- 
moved, and all bands must be loosened. 

When, as not infrequently happens in males, the abdo- 
men is very hairy, it must be first shaved, or, at least, the 
hair cropped close to the skin with a curved scissors; 
otherwise the hair will become matted by the massage, 
and the manipulations will be attended with considerable 
pain. Even a furunculosis may be excited if the hair is 
allowed to remain. 

The duration of a sitting is usually from five to fifteen 
minutes, according to the obstinacy of the case and the 
magnitude of the abdomen. It is desirable, especially for 
novices in the art, that the sitting be divided into two 
parts with an interval of rest between them. In this 
interval the patient can be allowed to rest upon the couch 
or to promenade up and down the room ; or he or she can 
execute certain gymnastic movements to be described fur- 
ther on, as the physician may think proper or necessary. 
For children a sitting of three to five minutes amply 
suffices. 

As to the amount of force to be used in the manipula- 
tions, that is difficult to describe. It can be laid down 
as a rule, however, that the massage, referring here to 
abdominal massage only, must never give pain, and to 
produce a bruise or an ecchymosis of the cuticle is a strik- 
ing demonstration of unskilfulness. The skilful masseur 



212 



CONSTIPATION IN ADULTS 



will never cause pain even when he works with some 
force. 

For abdominal massage the patient is placed on a couch 
or sofa with the head somewhat elevated and the knees 
drawn up so that head and knees shall occupy about the 
same plane ; thus : 




a, Head, c, Knees 



Where the couch is a level one, a pillow or two beneath 
the head, and the knees drawn up as shown in the cut (so 
that they shall constitute the apex of a triangle the sides 
of which are formed by the legs and thighs — the feet 
resting flat upon the couch), will answer. 

In this position the abdominal parietes are fully relaxed, 
and the internal organs can be readily reached. 

It happens occasionally that the manipulations are 
rather unpleasantly felt at the first sitting. This is due 
to the involuntary contraction of the muscles of the ab- 
dominal wall, and the resistance thus offered to the hand 
of the operator. This, however, soon disappears and 
the abdomen will remain relaxed unless the manoeuvres 



TREATMENT OF CONSTIPATION DUE TO ATONY 213 

are made with too much force, when the abdominal pari- 
etes will again become tense and thus shield the organs 
beneath them against too brutal an assault. If, after 
eight or ten sittings, the abdominal walls still remain 
firm, tense, without any tendency to relax, — and this 
despite all precautions, — or if but one side relaxes and 
the other side remains tense, then the question arises as 
to the correctness of the diagnosis and whether or not the 
products of an inflammatory process or a heterologous 
formation underlie and are the cause of this unyielding- 
ness on the part of the abdominal muscles. 1 A very 
interesting and illustrative case is related by Reibmayer. 2 
This is a point of the ^greatest importance and to be 
well borne in the mind, especially when we have to 
deal with women, in whom such conditions are not of 
rare occurrence. 

The masseur sits or stands to the right of the patient. 

He must see to it that the clothes of the patient are not 
soiled with the fatty matter used for anointing his fingers. 
This is readily accomplished by means of a towel laid over 
the clothes folded back from the belly. 

I myself prefer to make the massage dry, i.e. with 
unanointed fingers, according to the advice of Kellgren, 3 
for the reason that I believe that in this way a greater 
and better effect is obtained. 

Operative Technic. — The manipulations employed in 
abdominal massage may be divided, for a better compre- 
hension of their purpose, into the following groups : 

1 Reibmayer, Die Unterleibs-Massage. 

2 Loc. cit. 

3 Kellgren, loc. cit. 



214 



CONSTIPATION IN ADULTS 



A. Manipulations addressed to the abdominal walls where 

these are relaxed. 

B. Manipulations addressed to the small intestines. 

C. Manipulations addressed to the large bowel. 

D. Manipulations addressed to the nerve centres. 

E. Closing manipulations, or manipulations addressed to 

all the abdominal organs. 




Division of the Belly with One Hand. (R.) 

A. Manipulations addressed to the Abdominal Walls 
where they are relaxed. 1. Division of the Belly ivith 
one or Both Hands. — The thumb fully abducted from the 
hand, with the radial surface of the index finger, forms 
the crescent-like instrument with which the manoeuvre 
is made. The belly is divided transversely, from right to 
left, the part of the hand described pressing down into it 
and moving at the same time slowly from above down- 
ward. A somewhat lateral motion is also given to the 



TREATMENT OF CONSTIPATION DUE TO ATONY 215 

hand. The movement is made with the elbow and wrist 
joint. 

If the manoeuvre is made with two hands, when the 
belly is very large, then they move in opposite directions, 
from the middle outward and again inward. 

2. The Rolling of the Belly. — The flat hand and adjoin- 
ing surface of the forearm are placed over the abdomen, 




Division of the Belly with Two Hands. (R.) 

and with this the abdominal walls are rolled to and fro 
as a dough is rolled with a rolling pin. 

If the belly be very large, then the manoeuvre is carried 
out with the aid of an assistant. The assistant, to the 
left of the patient, places his hand as described. The two 
hands cross each other, and then with united force the 
manipulation is made. 1 

1 Reibmayer, Die Unterleibs-Massage, 1889. 



216 



CONSTIPATION IN ADULTS 



3. (a) Petrissage or Kneading of the Abdominal Walls. 
— Beginning in the right inguinal region, a section of the 




Rolling of the Belly with One Hand. (R.) 

abdominal parietes is taken up between the palmar sur- 
face of the hand and the forefinger and thumb and rolled 




Rolling of the Belly with Two Hands. (R.) 

and rubbed between them with some force. Whilst the 
right hand, with which the movement is begun, is thus 



TREATMENT OF CONSTIPATION DUE TO ATONY 217 

engaged, the left hand is passed over and beyond it, takes 
up an adjoining section and carries out the same movement. 

In this overhand way the manipulation is carried on 
until the whole abdominal wall has been kneaded. 

(b) According to Berne, it can be made in this wise : 1 




(c) It can also be made with the hand in the form of 
the " Kammgriffi." See cut on page 218. 

The manipulation in this form is made with the knuckles. 

In this way a certain amount of petrissage of the intestine is 
also made. The movement is often rather painful, and it is 
best therefore not to press down forcibly or deeply, but to make 
it rather superficially. 

(d) According to Reibmayer, 2 the manipulation is some- 
times very difficult of execution for the reason that the 
abdominal muscles contract at once strongly and firmly, 
and all kneading is out of the question. When this is 
the case, we must proceed very gently and make the 

1 Berne, loc. cit. " Loc. cit. 



218 



CONSTIPATION m ADULTS 




Kammgriff. 



manipulation after this fashion, with both hands : One 
hand, the fingers lightly flexed (a loose fist), is placed on 
one side of the belly ; the other hand, open, is placed to 
the other side and both work towards each other, the 
abdomen being pushed now to one side and then to the 
other. 

4. Punctation. — This manipulation is rather irritat- 
ing and stimulates the abdominal muscles to powerful 
contractions. The index fingers of the two hands are 
employed for this manoeuvre. They are raised and brought 
down alternately upon the abdominal parietes without 
any especial force. The whole abdomen is thus gone over. 



TREATMENT OF CONSTIPATION DUE TO ATONY 219 




Kneading of the Belly. (R.) 




Punctation. (B.) 



220 



CONSTIPATION IN ADULTS 



B. Manipulations addressed to the Small Intestines. 1. 

Vibration of the Small Intestines. 1 — The operator places his 
hand flat upon the umbilical region of the abdomen, and 
by an equable pressure, intermittent and continued for ten 
to fifteen seconds, communicates the vibrations of his hand 
to the small intestines. After an interval of rest, equiva- 
lent to the time occupied in the manoeuvre or longer, 
according to the indication, the manipulation is resumed. 
It can be repeated three or four times. 

2. Shaking of the Small Intestines. — The hand is laid 
flat upon the umbilical region, and then its borders — on 

one side the ulnar 
border of the little 
finger, on the other 
the radial border of 
the thumb — are 
gradually pressed 
deeper down, so 
that the small in- 
testines are forced 
up into the hollow 
of the hand. The 
hand is held firmly 
in position and, 
holding to the parts 
beneath, makes rapid to-and-fro and partly rotatory move- 
ments. 

3. Circular Efftenrage! 1 — This is a circular stroking 

1 1., Estradere, Du Massage, son Historique, etc., Paris, 1863. Le Mari- 
nel, loc. cit. 

2 Leon Petit, Le Massage par le Medecin, Paris, 1885. Le Marinel, loc. 
cit. 




Circular Effleurage. 



TREATMENT OF CONSTIPATION DUE TO ATONY 221 

movement made with three fingers of the right hand 
around the umbilicus as a centre. The thumb is placed 
below the umbilicus, and acts as a point of support, whilst 
the three fingers sweep around the umbilicus in a circle. 

The effect of this movement can be heightened by en- 
larging the circle described, and by exercising an inter- 
mittent pressure with the fingers. 

This manoeuvre is said to be very irritating, especially 
to nervous females. The firmer, however, the pressure, 
the less irritating the movement. It seems then to have 
a quieting effect on the peristalsis. It is said to act 
chiefly reflexly. 1 

C. Manipulations addressed to the Large Bowel. — For 
these various manipulations the patient must hold his 
abdominal walls relaxed. 

1. (a) Manipulation intended to break up Accumulated 
Fmces? The operator to the right of the patient, facing 
him. — The extended fingers of both hands are placed 
over the caecum, and then with the pulps of the fingers 
deep pressure is made, so as to break up 
the accumulated and hardened material 
by pressing it down against the posterior 
wall of the pelvis. Whilst the ringers /([[jM/t til 
are in this position, the arms as a whole 
make a rotatory movement and very 
short lateral motions from right to left, 
so that the manoeuvre may be more effective. The hands 
are carried over the whole tract of the large bowel down 
to the terminus of the sigmoid flexure. 

Or (b) the manipulation may be made in this way, 

1 Reibmayer, Die Unterleibs-Massage. 2 Le Marinel, loc. cit. 




222 



CONSTIPATION IX ADULTS 



which is perhaps more efficient : The extended ringers 
of both hands are placed over the csecum so that the 
dorsal surfaces almost face each other, i.e. one palm 
fronts toward the feet, the other to the right and some- 
what upward. 




To break up Indurated F^ces in Cecum and Ascending Colon. 

Then the fingers execute a piano-playing movement 
over the part. In this way, and while executing this 
piano-playing movement, the fingers are promenaded over 
the large bowel, from right to left, to the descending colon. 
At this point the position of the hands is changed, the right 
hand is placed just below the margin of the costal arch, 
over the descending colon, with the palm facing downward 
to the feet ; in front of it (downward) is the left hand, 
its dorsal surface fronting to the right palm ; the manipu- 



TREATMENT OF CONSTIPATION DUE TO ATONY 223 

lation is then made, as already described, down the de- 
scending colon to the terminus of the sigmoid flexure and 
beginning of the rectum, at which point the fingers are 
made to dip in more deeply. They are then removed 
and carried back to the point of beginning. The manoeuvre 




To break up Indurated Faeces in Transverse Colon. 

can be repeated two or three times, especially in the early 
stages of treatment. 

It has also the further effect of pressing scibala out of 
the sacculi of the gut. 

With the same object in view the manipulation for the 
transverse colon may be made thus : The four fingers of 
both hands, flexed somewhat at the knuckles (the articu- 
lation between the first and second phalanges), are placed 



224 CONSTIPATION IX ADULTS 

with their tips resting on the transverse colon, just beyond 
the right colic flexure to the left. The thumb, abducted, is 
placed below these, and, resting rather firmly upon the 
abdomen, forms a point of support for the other part of 
the hand. The piano-playing movement, as already 
described, is made with the fingers ; alternating with this 
a rotatory movement is made with them so that a series of 
small circles are described by them individually and 
synchronously. 

In this way the whole transverse colon is gone over. 

For the descending colon and the sigmoid flexure this 
manipulation can also be made in this wise : The three 
fingers of the right hand flexed lightly at the knuckles, 
and placed so as to rest with their tips over the point of 
beginning of the descending colon. The thumb, extended 
and resting firmly on the belly, supports the hand. 

The fingers holding firmly to the abdominal cuticle, so 
as almost to be one with, it, make a series of circular move- 
ments ; in these at first a small circle, then, gradually, 
larger and larger ones are described ; then they are lessened 
in size, made smaller and smaller, until the fingers have 
again returned to the point of beginning. The whole de- 
scending colon and the sigmoid flexure are thus gone over. 

2. (a) Intended especially for the Liver and the Colon 
Ascendens. — The hand is laid flat upon the belly, — 
almost at right angles to its arm, — the heel of the hand 
in the right inguinal region, and the fingers extending 
obliquely upward toward the navel. 

The palm of the hand, especially the ball of the thumb 
and of the little finger, presses down more deeply and 
more forcibly, whilst the fingers lay on but lightly and 



TREATMENT OF CONSTIPATION DUE TO ATONY 225 

make no pressure at all. The ulnar border of the hand is 
pressed down deeper than the radial, so that in this direc- 
tion also the hand has a somewhat oblique position. This 
is done so as to force the liver from below between the 
hand and the diaphragm, and thus exercise a moderate 
pressure upon it. The hand now makes a circular move- 
ment, as indicated in the cut, upward and outward until 
it comes in contact with the border of the costal arch. 
Here it makes a small turn, whereby the arm of the 




Fob Colon, Liver, and Gall Bladder. 



operator is somewhat abducted from his body. The hand 
then travels to the left over the epigastrium along the 
lower boundary of the costal arch and over the left colic 
flexure on to the descending colon, and down until its 
ulnar border touches the left anterior superior spine of 
the ilium. It is now carried down along; the sigmoid 
flexure, downward and inward, and directly across the 
region of the bladder — the elbow joint and arm of the 
operator approaching his body — to the point of beginning. 



226 CONSTIPATION IN ADULTS 

In making this manipulation, the wrist is held rather 
fixed, the movement being more of the elbow and shoul- 
der joints. Placed thus, a fair amount of force may be 
used in the manipulation without undue fatigue to the 
operator. 

In making the manipulation, avoid coming into forcible 
contact with the bony processes, the anterior superior 
spines of the ilium and the lower borders of the tenth 
ribs, otherwise considerable pain may be caused. 

The effects of this manoeuvre are directed principally 
to the colon ascendens, the liver, the gall bladder, some- 
what to the transverse colon, and, when practised as 
described here, the descending colon, the sigmoid flexure, 
and the lower section of the small bowels are also acted 
upon. It finds its main indication in hepatic disease 1 and 
in constipation due to such. 

As almost all cases of habitual constipation are attended 
with some torpidity of the liver, I generally employ it, 
but only the first part of the manoeuvre, that which acts 
upon the ascending colon, the liver, and the gall bladder ; 
the second part of this manipulation, i.e. that from the 
epigastrium to the left, I omit, preferring other move- 
ments of greater efficiency so far as these parts are 
concerned. 

3. Manipulation for the Whole Large Bowel; Transfer 
Movement. — (a) The operator places himself so that he 
faces the feet of the patient. The right hand is laid flat 
on the right inguinal region over the caecum, with the 
heel of the hand toward the costal arch and the fingers 
pointing toward the thigh. The left hand is so placed 

1 Reibmayer, loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 227 

that its bent fingers rest upon the second phalanges of the 
right hand. 

This is done so as to increase the depth of the pressure. 
The fingers of the right hand are made to dip in gra- 
datim, so that the deepest pressure is made with the 
tips of the fingers. The hand is now drawn up towards 
the costal arch, over the caecum and colon ascendens as 
well as over the right colic flexure or the region where it 




For Cecum and Colon Ascendens. (R.) 

is supposed to lie. The hands are then removed, replaced 
at the point of beginning, and the manoeuvre repeated a 
second and a third time. 

(b) The operator now turns around face to face with 
the patient (to the right of him — or, what I regard as a 
more convenient position, wherein greater effectiveness 
can be obtained, on the left side of the patient), and plac- 
ing his hands in the manner already described, with the 
tips of the fingers about the region of the right colic 



228 



CONSTIPATION IN ADULTS 



flexure or beginning of the transverse colon, he carries 
them over the transverse colon, the left colic flexure, and 
the beginning of the descending colon. 

Repeated three or four times. 

(c) The physician again on the right of the patient, 
face to face with him. The right hand is placed over the 
descending colon with the tips of the fingers touching the 




Fob the Transverse Colon. 

left half of the costal arch. The left hand is placed upon 
the right in the manner already described in (a), and the 
same manoeuvre carried out from above downward over 
the descending colon and the sigmoid flexure. About the 
brim of the true pelvis, at the symphysis pubis, the fin- 
gers are pressed in still deeper so as to press upon the 
annulus of the rectum. 



TREATMENT OF CONSTIPATION DUE TO ATONY 229 

This is repeated three or four times. 

The object or purpose of this manipulation is to hasten 
the carriage forward of the matters that have been broken 
up by the manipulation previously described. 

In cases in which it is difficult to execute this manoeuvre 
over the transverse colon with the four fingers as de- 




For the Descending Colon and Sigmoid Flexure. 

scribed, and this may happen, more particularly, in men 
with very heavy abdominal parietes, it can be made with 
two fingers only (the first and the second), reinforced by 
the same fingers of the other hand ; or it can be made 
with the thumb alone, as in children, considerable force 
being used. (See Part II., " Massage.") 




230 CONSTIPATION IN ADULTS 

4. Petrissage of Different Portions of the Large Bowel} 
— (a) This manipulation is made by sinking the hands 
down deeply into the abdomen of the patient and grasp- 
ing, successively, diverse parts of the large bowel, begin- 
ning with the caecum, and rolling 
and kneading them between the 
thumb and four fingers. 

To act upon the caecum and as- 
cending colon, the operator stands 
to the left of the patient, so that the 
four fingers shall be on the outer, 
and the thumb on the inner, side. 

For the descending colon the operator places himself to 
the right of the patient. 

This movement is rather difficult of execution, espe- 
cially for novices, sometimes even for experienced mas- 
seurs, as in cases where there is a marked panniculus 
adiposus, or where the patients will persist in keeping 
the abdominal walls tense. 
Under these circumstances it 
may be carried out in this 
wise : The ulnar borders of 
the two hands are sunk down 
deeply into the abdomen, one 
on the outer and the other on 

[Le M.) 

the inner side of the gut, so 

as to get it between the two palms between which it is 

then rolled and kneaded. 

(b) I make the movement in this way : The flat hand 
is placed over the section of the gut to be kneaded ; then 

1 Le Marinel, loc. cit. 




TREATMENT OF CONSTIPATION DUE TO ATONY 231 

the four fingers on one side and the abducted thumb on 
the other are sunk down into the abdomen, gradually 
deeper and deeper, until the gut is seized ; it is then rolled 
and kneaded very gently between the fingers and the 
thumb. 

As to how to get hold of the various portions of the 
large bowel, this has already been set forth fully in the 
chapter on " Diagnosis." 




Kneading and Raising of Sigmoid Flexure 



D. Manipulation addressed to Nerve Centres. Vibra- 
tion of the solar plexus. — Vibrations and the technique of 
their production have been already described. They are 
employed more especially in the treatment of nervous 
ailments, after the manner devised by Kellgren. 1 In the 
treatment of habitual constipation, the only manipulation 
made coming under this head is vibration of the solar 
plexus. 

1 Loc. cit., " Nerve Vibrations." 



232 



CONSTIPATION IN ADULTS 



The solar plexus lies in front of the abdominal aorta, 
about the middle of a line drawn from the xiphoid carti- 
lage to the umbilicus. The tips of the four fingers, ex- 
tended or slightly flexed at the knuckles, are placed upon 
this line, and about this point, are pressed in deeply, and 
the vibratory manoeuvre carried out. 




Vibration of Solar Plexus. (R.) 



E. Closing Manipulations ; Manipulations addressed to 
all the Abdominal Organs. — Abdominal massage is closed 
with a series of manipulations described as "tapote- 
ment " (percussion), the varieties of which have already 
been named. These manoeuvres are based upon certain 
physiological investigations of Golz, 1 and are believed to 
effect in a manner, directly or refLexly, all the abdominal 
organs. 

1 (Klopfversuche) Beitr'age zur Lehre von den Funktionen der Nerven- 
centren des Frosches, Berlin, A. Hirschwald, 1867. 



TREATMENT OF CONSTIPATION DUE TO ATONY 233 

It is very evident, therefore, that movements of such 
gravity must be carefully made, and in such a way that 
no possible injury can result therefrom: The gravity of 
a blow upon the abdomen, and the serious consequences 
that might result from one badly administered, must be 
constantly borne in mind. In fact, it can be formulated, 
as a rule, as has already been said, that force — brute 
force — has no part in the manipulations of abdominal 



Hacking of the Belly. 



massage, and that the operator who causes his patient 
pain has yet to learn the rudiments of his art. 

Tapotement. — The manipulations are made with the 
abdomen drawn tense, always. 

1. Hacking (Hacliure). — This is a manoeuvre the exe- 
cution of which requires some skill. It is made in this 
way : The fingers of the hand are separated from each 
other, and the hand, hanging loosely as it were in the 
wrist joint, is allowed to fall on the abdomen (the walls 
of which had been previously contracted), but in such a 



234 



CONSTIPATION IN ADULTS 



way that only the ulnar surface of the little finger, pha- 
langes and small portion of adjoining metacarpal bone, 
are allowed to come in contact with it. The fingers in 
falling close together like the leaves of a fan. The blow 
thus struck is elastic and painless. Some also allow the 




Clapping of the Belly. (R.) 



ulnar surface of the ring finger to come in contact with 
the belly, making thus two blows struck in rapid succes- 
sion. Both hands are used in this manipulation, and they 
move in opposite directions, the one falling whilst the 
other rises. 

2. Clapping. — Clapping is executed with the flat hand 



TREATMENT OF CONSTIPATION DUE TO ATONY 235 

(hand fully extended), with the palmar 1 or dorsal surface/ 
according to the effect desired to be obtained. 

When the dorsal surface of the hand is employed, it is 
with the dorsal surface of the two last phalanges of the 
fingers only that the movement is executed. 

Where we desire the action to be very mild, the manipu- 
lation can be made in this way : The hand is hollowed so 




Tapotement a l'Air Comprime. (R.) 

that it holds within its boundaries a certain volume of 
air. As it descends upon the belly, this volume of air in 
the falling hand becomes compressed, and when the belly 
is struck, it is rather by this cushion of compressed air 
than by the hand. This is known as " tapotement a l'air 
comprime," percussion by means of compressed air. 

1 Made in this way, it is said to have a calming effect. Georges Berne, 
loc. cit. 

2 Exciting, stimulating effect, like hacking. 



236 



CONSTIPATION IN ADULTS 



3. Beating of the Belly. — When percussion is made 
with the fingers drawn into the palm of the hand, so as 
to almost make a fist, but still hollow, a sort of air-cushion 
between the palm and the palmar surface of the fingers, 
it is called beating. Not much employed. 

The following movement comes into use, in so far as 
we are here concerned, only in cases of habitual constipa- 
tion complicated with haemorrhoids or with congestion of 
the rectum, or of one or the other organs of the female 
genital tract. 

4. Beating the Sacrum (Kreuzbein Klopfung). — The 
patient, with one leg in advance of the other, bends the 

body far forward, and 
supports him- or herself 
by resting the hands 
upon a low stool. The 
operator places himself 
to the left of his patient, 
clenches his hand in the 
manner just described in 
No. 3, and allows it to 
fall upon the sacrum. 
As it comes in contact 
with the latter, the air- 
cushion is displaced and 
the hand firmly closed. 
Carried out in this way, 
the blow is more elastic and much less painful. Though 
essentially a movement of the forearm, still the wrist must 
not be immobilized, but must participate in the motion. 
The beating is done in a circular direction. This ma- 




Beating of the Sacrum, (is!.) 



TREATMENT OF CONSTIPATION DUE TO ATONY 237 

noeuvre, introduced by Brandt, is said to have a powerful 
resorbent, antiphlogistic action. 1 

It will of course be readily understood that all the 
manipulations here described are not needed in all cases. 
Thus, where the abdominal muscles are not relaxed, as in 
the young and in many males, the manoeuvres designed for 
the abdominal parietes, group A, can certainly be omitted. 
Again, in cases where there is but moderate relaxation of 
the abdominal walls, some only of these manipulations will 
be necessary, whilst the others may be omitted. Moreover, 
all masseurs or operators adopt a certain limited number 
of manipulations which they make by preference and in 
the execution of which they acquire great skill. 

However, the physician — and I hold that massage 
is as much his province as the setting of a fracture or 
the application of electricity — should familiarize himself 
with most, and if possible all, of the manipulations here 
described, and be prepared to make them. This for the 
reason that my experience, limited somewhat though it 
be, has demonstrated to me that with massage, just as 
with medicines, in chronic cases a change from time to 
time in form and mode of administration is of the greatest 
advantage. The system becomes as readily accustomed 
to certain manipulations, and does not react to them as 
energetically any more, as it does to certain drugs. 

I schedule my manipulations about as follows : 

Case 1. No special relaxation of abdominal walls. 

First Week. Introductory Effleur age. — In all cases, whether 
the manipulations of group A are required or not, I make, at 
the outset of the treatment, a very light introductory effleurage 

1 Reibmayer, loc. cit. 



238 



CONSTIPATION IN ADULTS 



merely to accustom the abdomen to the touch of the operator. 
It is done in this wise: the abdomen is stroked lightly with 
the flat of the hand, or rather of the fingers, from the epi- 
gastrium to the symphysis pubis, and from the right and left 
boundaries into the linea alba, a hand being placed on either 
side. In females with uterine disorders of a congestive character 
the efneurage is made in accordance with the rule, from the peri- 
phery to the centre, -i.e. from the symphysis to the epigastrium. 

Second Week. 

Manipulation, Group (7, 1, b Manipulation, Group C, 1, b 

Manipulation, Group (7, 2 Manipulation, Group (7, 2 

Manipulation, Group (7, 3, #, 5, c Manipulation, Group (7, 3, a, b, c 

Manipulation, Group B, 2 Manipulation, Group (7, 4 

Manipulation, Group i>, 1 Manipulation, Group E, 2 
Manipulation, Group E, 1 

Case 2. Considerable relaxation of the abdominal walls. 



First Week. Introductory 
Effleurage. 
Manipulation, Group A, 3, a 
Manipulation, Group A, 4 
Manipulation, Group (7, 1, b 
Manipulation, Group (7, 3, a, 6, c 
Manipulation, Group B, 2 
Manipulation, Group D, 1 
Manipulation, Group E, 1 

Case 3. Pendulous belly. 
First Week. Introductory 
Effleurage. 
Manipulation, Group A, 3, c 
Manipulation, Group A, 4 
Manipulation, Group A, 1 
Manipulation, Group (7, 1, b 
Manipulation, Group (7, 3, a, 6, c 
Manipulation, Group B, 2 
Manipulation, Group D, 1 
Manipulation, Group E, 1 



Second Week. 
Manipulation, Group J., 1 
Manipulation, Group J., 3, a, c 
Manipulation, Group A, 4 
Manipulation, Group (7, 1, b 
Manipulation, Group (7, 2, a 
Manipulation, Group (7, 3 
Manipulation, Group (7, 4 
Manipulation, Group E, 2 

Second Week. 

Manipulation, Group A, 1 
Manipulation, Group A, 3, a 
Manipulation, Group A, 2 
Manipulation, Group (7, 1, b 
Manipulation, Group (7, 2 
Manipulation, Group (7, 3, a, 5, e 
Manipulation, Group (7, 4 
Manipulation, Group j£, 2 



TREATMENT OF CONSTIPATION DUE TO ATONY 239 

These schedules are used alternately, one week the one 
and the following week the other, and thus on throughout 
the whole period of treatment. It is of course understood 
that the requisite changes are made in the programme 
whenever the necessity therefor arises ; e.g. we will omit 
the more powerful manipulations, when from indiscre- 
tions on the part of the patient colicky or spasmodic 
conditions accidentally supervene, and confine ourselves 
to the mild and soothing efHeurage movements. 

Frequency of Treatment. — The patient should have no 
less than three treatments per week, — every other day is 
better, — and this with the greatest regularity. 

Usually in a very short time after the inauguration of 
the massage treatment, sometimes after two or three 
sittings, and in rare instances already after the first, 
the bowels will begin to move regularly every day, and 
patients may feel inclined to lessen the number of sit- 
tings per week. Still, as the stools are as yet hard and 
scibalous and insufficient in quantity, and as relapse 
readily occurs, the physician should insist most strenu- 
ously upon three sittings per week as an absolute neces- 
sity. Only when the stools have again resumed their 
normal form and are of sufficient quantity can the num- 
ber of sittings per week be lessened. 

One treatment per week or an occasional treatment 
cannot give any satisfaction, either to physician or patient. 

Duration of Treatment. — Under very favorable condi- 
tions six weeks may suffice, and the bowels, then function- 
ing normally, will continue to gain in strength and vigor 
from their own physiological action. Under other con- 
ditions three months may be required, and this is about 



240 COXSTIPATIOX IN ADULTS 

the average period. This is also the experience of Le 
Marine!. 1 It may even take longer. The dictum of that 
eminent clinician Nothnagel is, "Continue until success 
is achieved, even if it takes months and months." 2 

Mode of Cessation. — I believe, and I carry this doctrine 
into practice, that the cessation of massage should be 
gradual. The rationale thereof can be readily under- 
stood ; we have so many analogous instances in medicine, 
and it was so essential a principle with the older physi- 
cian, that details as to the why and wherefore are not 
necessary here. When the patient has had three sittings 
per week, or every other day regularly for six weeks or 
any other period, and the bowels are acting regularly and 
normally, we reduce the number to two, then to one sit- 
ting, per week, and lastly to one in two weeks. We re- 
duce the number of manipulations, omitting gradually 
the more powerful ones. Then the patient can be dis- 
charged. In this way we fortify the good results already 
obtained, guard against relapses, and keep our patient 
under observation for a sufficient length of time to be 
fully assured as to the outcome of our treatment. 

********** . 

Instrumental Massage. — It has been suggested, and no 
doubt from pecuniary considerations and from reasons of 
delicacy, as where the operator is other than a physician, 
that mechanical appliances be used for the carrying out 
of massage treatment. Sahli 3 has suggested the use of a 

1 Loc. cit. 

2 Wiener medizinische Presse, loc cit. 

3 " Ueber Massage des Unterleibs mittelst Eisenkugeln," C orrespondenz- 
blatt Schiceizer Aerzte, XVII. 19, 1886. 



TREATMENT OF CONSTIPATION DUE TO ATONY 241 

three- or five-pound old-fashioned cannon-ball covered with 
chamois-skin. This is to be rolled over the tract of the 
whole large bowel by the patient himself, either before 
rising in the morning or on retiring at night, or at both 
times. Dr. Ach. Rose has claimed some success with this 
method. 1 

Dr. S. Feilchenf eld 2 has employed steady pressure in 
the treatment of constipation, with meteorism and atony 
of the intestine. He has made for this purpose a cushion 
containing three to four pounds of shot, which by means 
of thin layers of cotton-wool are divided into equal and 
even layers, and the whole then thoroughly quilted 
through. The cushion is made in the form of the belly, 
so as to fit it, and to exert, when on, an equable pressure 
upon it. By means of bands or tapes it can be tied to 
the body, and thus kept in position. 

It can be applied in the morning before rising, or at 
night on retiring ; in a few cases he has allowed it to 
remain on all night ; usually, however, an application of 
one-half to one hour has sufficed to call forth a regular 
stool. 

He has obtained good results with it also in hemor- 
rhoidal troubles. 

Dr. Arthur Kahn 3 has invented an apparatus for self- 
massage which is highly spoken of. 

This instrument is intended for the purposes of general 
massage, and not for that of the abdomen alone. 

As far as my own experience goes, I must say, referring 

1 New Yorker medic. Monatschrift, January, 1S93. 

2 Deutsch. medic. Zeitung, No. 75, 1891. 

8 Centralblatt f. Chirurg. u. Orthop. Mechanik, Berlin, 1889, V., p. 4, and 
personal communication. 



242 CONSTIPATION IN ADULTS 

here to abdominal massage only, that the mechanical 
appliances cannot replace the hand of the skilled opera- 
tor, and especially if that operator be a physician. How- 
ever, this much must be admitted, that whenever patients 
cannot, for any reason whatsoever, avail themselves of 
the services of a masseur, instrumental massage is the 




Kahn's Roller. 



best and only substitute. Likewise when patients cannot 
have the treatment at the hands of a masseur with suf- 
ficient frequency, the use of appliances (and those de- 
scribed here I hold to be the best) in the interval will 
add materially to the efficacy of the infrequent manipu- 
lations of the physician. 



CHAPTER XVII 

TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) 

Massage (continued); Swedish Movements. Kinesipathy 
(Heilgymnastih). — A branch of massage, and a not unim- 
portant one, is kinesipathy, or the Swedish movement 
cure, so specially designated because it was in Sweden 
where the system received its greatest elaboration and 
found its most general application. 

It is maintained by some that kinesipathy is a necessary 
complement of massage, and must always follow it, and 
that massage alone is not very effective. Without at all 
disputing the value of these exercises, especially for those 
morbid conditions that pertain to the domain of ortho- 
paedics as has been set forth by Bush, 1 I must say that 
so far as constipation is concerned I prefer that, when- 
ever possible, the patient shall take exercise in the man- 
ner described in Chapter XV., and I think it will be 
generally admitted that for this purpose such dietetic 
exercise is amply sufficient, really nothing else equal to 
it, and that kinesipathy, or medical gymnastics, can then 
be omitted from the list of measures to be employed - 

However, there are instances that come under observa- 
tion occasionally, where for one reason or another the 
patient cannot get the requisite dietetic exercise ; here 

1 Handbuch der Allgemeinen Therapie, Ziemssen, Bd II, Th. II. 

243 



244 CONSTIPATION IN ADULTS 

the movement cure will find excellent application, and 
add to the efficiency of our massage treatment. 

As to the physiological action of these movements, the 
same principles pertain here that have been set forth in 
the section on exercise in general. 

The movements are divided into three great groups : 

1. Active movements made by the patient himself 
without the assistance or interference of another person. . 

2. Movements against resistance. These movements 
always require an assistant. The resistance is offered 
now by the physician (or gymnast), now by the patient. 

3. Passive movements, where the patient himself is 
altogether passive, the movements being made by a second 
person. 

It is generally desirable for the greater ease and com- 
fort of the patient, and the greater facility with which 
the movements can be made, that a special garb, such as 
is used in all gymnasiums for the purpose, shall be worn 
by the patient whilst taking these exercises. (The usual 
suit of woollen underwear as worn by most men in this 
country will do very well. For ladies, if they prefer, a 
loose, sleeveless vest of woollen or thinner material, a 
pair of drawers, and high stockings will fill all require- 
ments.) It is not, however, indispensable ; only, if the 
ordinary garb be worn, we must see to it that all bands 
(neck bands, belly bands, garters) be loosened, so that 
both respiration and circulation shall be perfectly free 
and unimpeded. 

As to the number of movements to be made at each 
sitting, that is a matter that must be decided for each 
case individually. The rule laid down for dietetic exer- 



TREATMENT OF CONSTIPATION DUE TO ATONY 245 

cise, namely, that it should never reach the point of 
fatigue, holds good for medical gymnastics, and we will 
be governed therefore in our prescriptions by the habit 
and experience of the patient. We will, as a rule, begin 
with a smaller number and with weaker movements, and 
gradually, as the patient becomes accustomed to the exer- 
cise, increase the number of the movements or the fre- 
quency of repetition of each individual movement, as well 
as go over to such exercises as require greater force and 
greater exertion in their execution. 

Rules 

Begin with the weaker movements, put the more forci- 
ble in the middle, and close again with the weaker (about 
in the order of arrangement of the three groups here). 

The resistance movements should alternate with active 
movements of another part of the body. Thus after 
every such exercise the patient should take a turn for a 
minute or two the length of the room, or if the lower 
part of the body be engaged in the movements under 
resistance, he can make some of the active arm move- 
ments figured here. 

With the active and passive movements such pauses 
are not required. 

A gymnastic seance lasts from one-half to one hour. 

1. Active Movements 

These movements are, as already stated, made by the 
patient himself by the voluntary exercise of his muscles 
without the aid or interference of another person, and 
constitute the essence of what is known as chamber gym- 



246 



CONSTIPATION IN ADULTS 



nasties. They can be made as well at the home of the 
patients, in the intervals of treatment (by the physician), 
as in a regularly arranged gymnasium. 

Patients must be carefully instructed not to contract 
the muscles spasmodically in the making of the move- 
ments. The movements should be vigorous and regular, 
and not entail any unnecessary fatigue. 




Fig. 1. 

Bending of the trunk forward and 
backward. Five to ten times. 



Fig. 2. 
Lateral inclination of 
the trunk. Five to ten 
times. 



Fig. 3. 
Rotation of the trunk. 
Ten to fifteen times. 



Fig. 3. The patient, placing himself in the upright posi- 
tion, lower extremities firmly fixed, and with hands upon 
the thighs, rotates the trunk from right to left and left 
to right. 

Fig. 4. The person, placing himself as described above, 
rotates the trunk upon the hips from right to left and left 
to right, so that he shall describe a cone, the circular base 
of which shall be as extended as the lumbo-sacral articula- 
tion will permit. During all the phases of the movement 



TREATMENT OF CONSTIPATION DUE TO ATONY 247 




Fig. 4. 
Circular movement of the 
trunk with inclination, to 
the right and to the left. 
Three to six times. 



Fig. 5. Fig. 6. 

Extension and flexion of Extension and flexion 

knee, forward. Five to of knee, backward, 
ten times. Five to ten times. 




( 



Fio. 7. 
Raising the knee 
as high as possi- 
ble, anteriorly. 
Ten to fifteen 
times. 



Fig. 8. 
Squatting and ris- 
ing. Three to 
six times. 




Fig. 9. 

Wood-chopping movement. Two to 

six times. 



248 



CONSTIPATION IN ADULTS 



the trunk is always face forward so that no twisting of 
the axis of the body is entailed. 

This movement is determined by all the muscles of 
the hip. By the observance of a certain cadence, all 
the muscles of the abdomen are alternately called into 
activity. 1 

Fig. 10. The patient places himself upon a couch in the 




Fig. 10. 
Rapid elevation of the upper and lower part of the body, alternately. Four to eight 

times. 



horizontal position, and, folding his arms upon his chest, 
raises his trunk and upper part of the body into the 
upright position without moving his lower extremities. 
It may be a little difficult to accomplish at the outset, 
and assistance may be required at first to hold down the 
legs, but this soon passes and the patient can execute the 
movement quickly and with ease. 

Then the body is thrown back upon the couch and the 
legs are drawn up, the knees flexed upon the thighs, and 

1 Le Marinel, loc. cit. 




Fig. 10. 

Assistant holding down the legs. 



TREATMENT OF CONSTIPATION DUE TO ATONY 249 

the thighs upon the pelvis as far as they will go ; after 
holding them a few seconds in this position, they are 
extended vertically to their full height. Then these are 
lowered and the 
trunk raised, and so 
on, alternately. 

The movement of 
raising the trunk 
can be made still 
more difficult by 
placing the hands 
beneath the head, or 
by holding weights 
or dumb-bells in the hands and holding them near the body. 1 

This movement brings into play all the abdominal 
muscles, and through them (besides by the direct pressure 
brought to bear) influences all the abdominal organs. It 
is, therefore, the most important of all the movements 
that are made. 

II. Movements against Resistance 

These movements always require the assistance of a 
second person, a gymnast or a physician. The resistance, 
made in the course of these movements, is offered, now by 
the patient, now by the physician. Although a certain 
amount of force must always be used in the course of 
these exercises, it must never be so great that the resist- 
ance cannot be readily overcome, especially by the patient, 
so that he shall not be compelled to excessive contraction 

1 Le Marinel, loc. cit. 



!■ 



■■ 



250 



CONSTIPATION IN ADULTS 




of his muscles by which they will be thrown into a tremor, 

or that the physician shall 
be forced to unnecessary and 
useless exertion. All trials 
of strength are prohibited in 
medical gymnastics ; they 
prevent that equable and nor- 
mal contraction of muscle 
which it is the object of these 
exercises to effect. 1 

Fig. 1 1 . The patient stands 
with his legs spread apart and 
raises his arms over his head, 
so that the volar surfaces of 
the hands front each other. 
The physician places himself 

before the patient, grasps both his arms about the elbows, 

and bends the trunk, the 

patient resisting, at first 

to the right. Then the 

patient raises his body 

against the resistance of 

the physician. Then the 

movement is made to 

the left, and so on, al- 
ternately, three to five 

times for each side. 
Women can sit whilst 

making this movement. 
Fig. 12. The patient 

1 Reibmayer, Die Unterleibs-Massage 



Fig. 11. 

Standing spread. Alternating lateral 
inclinations. 




Fig. 12. 
Opposite-sitting. Trunk rotation. 



TREATMENT OF CONSTIPATION DUE TO ATONY 251 



sits upon a chair or ottoman or stool, with knees brought 
together and the arms akimbo, with the hands resting upon 
the hips. The physician sits opposite, facing the patient; 
places his hands upon the latter' s shoulders, and rotates 
the trunk, the patient resisting, to the right. Then the 
patient brings it back against the resistance of the physi- 
cian to the initial position. The movement is 
then made to the left. Three times to each 
side. 

Fig. 13. The patient places himself 
in a riding posture upon a high 
bench, and lays his head 
upon the left arm of the 
physician, who is behind 
him. The physician passes 
his left arm underneath 
the left arm of the patient, 
from before backward, al- 
lowing his hand to rest 
upon the patient's back. 
The right hand is pushed 
through from underneath the patient's right axilla, curves 
upward and forward so that the fingers come to lie upon 
the patient's shoulder. 

The physician now rotates the trunk toward the left, 
the patient resisting. The patient then brings his body 
back to the initial position, the physician offering the 
resistance. In making the rotations to the right, the 
physician changes the position of his hands, the right 
assuming that of the left, and the left that of the 
right. 




Fig. 13. 
Riding position. Trunk rotation. 



252 



CONSTIPATION IN ADULTS 




Fig. 14. 
Opposite-sitting. Trunk inclination. 



Fig. 14. The patient sits with closed knees upon a 
chair or stool with the hands resting upon the hips. The 

physician sits opposite, fac- 
ing his patient, places his 
hands upon the latter's 
shoulders, and bends the 
body forward, the patient 
resisting. The patient then 
straightens up again, the 
physician offering the resist- 
ance. 

Fig. 15. The male pa- 
tient is placed upon the high 
bench in riding posture. 
The physician stands behind 
him, places his hands upon his shoulders, and bends the 
body far forward, 
so that the whole 
abdomen is very 
well compressed, 
the patient mak- 
ing resistance. 
The patient then 
brings his body 
back to the initial 
position, the phy- 
sician now resist- 
ing. 

Fig. 16. The 
patient is placed 
in the position for abdominal massage, with the flexed 




Fig. 15. 
Riding posture. Trunk inclination. 



TREATMENT OF CONSTIPATION DUE TO ATONY 253 

knees in close apposition. The physician sits to the left 
of his patient, places his left hand upon the outer side 
of the patient's right knee, and the right hand upon the 
outer side of his or her left knee. 

The patient now spreads his knees apart, the physician 
resisting ; the left knee, in moving, comes in contact with 
the physician's left arm, and the right knee with the physi- 
cian's right arm. This makes the movements more equable 




Fig. 16. 

Half-lying. Knee separation, with lifting of sacrum. 

and less exhausting for the physician. Then the knees are 
brought together by the physician, the patient resisting. 

Fig. 17. The patient in the same position as for the 
previous exercise. The physician, to the left of the patient, 
places his hands on the inner sides of the latter' s knees. 
He now spreads the knees apart against the resistance of 
the patient, and the patient brings the knees together 
against the resistance of the physician. 

In females, with each of the two movements just described 



254 



CONSTIPATION IN ADULTS 



the patient raises her pelvis till it is almost on the same 

plane with the head and the knees. 

In males the elevation of the pelvis is unnecessary (ex- 
cept if atony 
and prolapse of 
the rectum be 
present, then 
the exercise is 
made just as in 
females). The 
resistance then 
not being as 
great, the phy- 
sician can place 
himself more 
to the feet of 
the patient, 




Fig. 17. 
Half-lying. Knee closure, with lifting of sacrum. 



facing him, as shown in cut. 




(a) Knee closure. 



(6) Knee separation. 



TREATMENT OF CONSTIPATION DUE TO ATONY 255 



Fig. 18. The patient squats down and holds himself in 
this position by resting his hands upon the pins of a mast 
(as in the cut) or upon the back 
of a chair. The physician, to 
the right of the patient, places 
his right hand upon the pa- 
tient's abdomen and his left 
upon the back, about the 
lumbo-sacral junction. The 
patient, holding his knees 
firmly together, now raises 
himself to the full upright 
position against the resistance 
of the physician. In raising 
himself, the patient describes 
an arc-line, upward and for- 
ward, with his pelvis. 

Fig. 19. The patient lies 
down upon a table, belly down- 
ward, but so that only the lower extremities rest upon the 
table, whilst the rest of the body is free therefrom and 
entirely unsupported. The feet must be held down upon 
the table by an assistant, whilst the patient must hold his 
body out in the horizontal position. 

As this movement entails a high degree of tension upon 
the abdominal muscles, the patient must be assisted at the 
outset in getting into position. It is done in this wise : 
The patient kneels upon the table, and after the feet have 
been fixed down by an assistant, the physician catches the 
patient with his arms under both axillce and brings him 
into the desired posture. He then lets go, allows the 




Fig. 18. 
Squatting with arc-like rising. 



256 CONSTIPATION IN ADULTS 

patient to retain this horizontal position for a few seconds, 
and again placing his hands upon the patient, about the 
region of the false ribs, brings him back to the kneeling 
position upon the table. 

This exercise has an invigorating and strengthening 
effect upon the muscles of the belly, the "back, and the 
loins. 

III. Passive Movements 

Movements in which the patient is altogether inactive. 

Fig. 20. The patient places himself in the semi-recum- 
bent position. The physician, standing by the side of the 
patient, lays one hand upon the patient's knee, and with the 
other he grasps the foot about the metatarsal bones or about 
the ankle joint, and now makes rapid flexion and exten- 
sion in the hip joint. This alternate flexion and extension 
of the hip joint is repeated six or eight times for each leg. 

The knee must not be flexed too strongly in making 
the movement. 

Fig. 21. The patient kneels upon an ottoman or cushion. 
The physician, standing behind, places his hands firmly be- 
neath the patient's axillae and rotates the trunk with a 
rather rapid motion (no resistance must be offered by the 
patient) ten to twelve times. A short pause can be made 
in the middle of the exercise. 

Fig. 22. The patient sits upon a high bench or upon a 
narrow stool, with his arms akimbo and with the hands upon 
his hips. The physician or gymnast places himself behind 
the patient, lays his two hands upon the latter's shoul- 
ders, and rolls his trunk, the patient making no resistance 
at all, three times to the right and thrice to the left. As 



TREATMENT OF CONSTIPATION DUE TO ATONY 257 




Fig. 19. 
Lying over ; holding trunk. 




Fig 20. 

Half-lying, thigh-flexing, and pressing down of 

knee. 



Fig. 21. 
Trunk rotation. Kneeling posi- 
tion. 



258 



CONSTIPATION IN ADULTS 



the physician or gymnast only controls the movements, 
it devolves upon the patient to maintain his equilibrium, 
that is, to call gradually into activity all the muscles that 
balance the trunk. During the movement, the head and 
upper part of the body are to be held as straight as pos- 
sible. The movements must not be jerky, and the shoul- 
ders must always be turned on the same plane. 




Fig. 22. 
Trunk-rolling. Riding position. 



Fig. 23. 
Hip rotation. Standing posi- 
tion, with arms elevated. 



Fig. 23. Patient stands with the legs well together, ele- 
vates the arms fully above the head, and, separating them 
widely, grasps a pole (which hangs down from above, or 
which is merely placed in his hands). The physician, be- 
hind, places his hands upon the patient's hips, and whilst 
the latter, with feet firmly planted, seeks to maintain the 
upright position, the physician rotates the pelvis rapidly 



TREATMENT OF CONSTIPATION DUE TO ATONY 259 

around in a circle to the right three to six times and as 
many times to the left. The patient's pelvic and hip mus- 
cles must be as passive as possible during the movement. 

In cases of flabby abdominal walls, or even pendulous belly, 
so often met with in married women, and in the large, full, 
rounded abdomens indicative of an abundant panniculus adi- 
posus, the movements shown in Fig. 10 of Group I., and that 
shown in Fig. 20 of Group II., are especially indicated and 
of the greatest service. 

Machine Movement Cure ; Machine Gymnastics 
(Maschinelle Heilgymnastik) 

I. Dr. G. Zander, of Stockholm, 1 invented and per- 
fected a series of machines by which the resistance 
movements and the passive exercises can be made with 
but little loss of time. In many of the large cities of 
Europe, and in one or two in America, special institu- 
tions have been established, fitted out with the machines, 
and operated for the sole purpose of thus treating 
patients. If such an institution is at hand, the physi- 
cian, if he so desires, can avail himself thereof, and 
recommend his patient thereto, for the gymnastic part 
of the treatment. 

It must be stated, however, that, in the opinion of 
experts in this matter, the machine method has no other 
advantage over the manual than that of greater facility 
and greater rapidity in the handling of patients. 2 

II. When such an institution is not convenient, and 
when, for any reason whatever, the physician himself 
cannot give the patient the benefit of the second and 

1 Bush, Reibinayer, loc. cit. 2 Reibmayev, loc. cit. 



260 CONSTIPATION IN ADULTS 

third group of gymnastic exercises, he can avail himself 
of certain other mechanical devices for resistance exer- 
cises which the patient can readily use at his own home. 

Such machines are : the rowing apparatus of Sachs 
(Fig. 24), the rowing apparatus of Ewer (Fig. 25), and 
the restaurateur of Sachs (Fig. 26). 1 

For greater safety, a thick cord of a certain length is run 
through the rubber tubing of the different Sachs machines, so 
that in case of a break or tear, the patient will not fall back 
and do himself injury. 



Contra-indications to Massage 

When not to practise it. — In all cases where, upon examina- 
tion, the bowels are found to contain very much indurated 
faeces, masses of stone-like hardness that cannot be readily 
broken down with the fingers, massage treatment will not be 
instituted until the intestinal canal has been thoroughly cleared 
by means of injections of water, of oil, by means of oil adminis- 
tered freely by mouth, and reinforced by clysters, by means of 
the scoop, or even of the hand. 2 Otherwise there is danger 
of lacerating, or even of perforating, the intestine in the course 
of the manipulations. 

During the menstrual period, the treatment should be inter- 
mitted. It should not be resumed till a few days after the 
cessation of the flow. 

In chronic diseases of the female genital tract, as 
pelvic cellulitis, retro- or peri-uterine haBmatocele, chronic 
inflammation of the ovary, of the tube, we must refrain 
from the more forcible, from the more powerful, manip- 
ulations, already described. We will confine ourselves 

1 Reibmayer, loc. cit. 2 See History, p. 148. 



TREATMENT OF CONSTIPATION DUE TO ATONY 261 





Fig. 25. 

a, middle section of the boat ; I, seat run- 
ning on a rail ; k, movable footboard ; h, rud- 
der that can be carried in any direction by- 
reason of c, d, i, ball and socket joints ; b, ar- 
rangement to hold the rudder firmly. In the 
brass tube /, a piston-rod is worked up and 
down by the rudder, and to effect its easier 
return a spiral spring is arranged in the tube g. 

To make the work accord with the strength 
of the worker, the following further arrange- 
ments have been provided thereon : The centre 
of motion of the rudder is movable ; the nearer 
it approaches to c, the more easily the move- 
ments are made. In the tube/, at the point i, 
there is a slit which can be entirely closed or 
kept more or less open by a ring. The larger 
the opening, the more freely the air can rush 
in under the piston, and the easier the work 
will be. 



a, Movement with Sachs Restaurateur. 



Fig. 




b, Goodyear's Pocket Gymnasium. 



262 CONSTIPATION IN ADULTS 

here to the mild effleurage and very gentle and rather 
superficially made frictions ; 1 still, so, that whilst having 
due regard for the pathological conditions present, we 
shall obtain regular action on the part of the bowels, 
which in itself will have a reflex curative effect. 




Case with greatly enlarged Spleen. 

A. Outline of Spleen. 

B. Line of Massage for Sigmoid Flexure and beginning of Rectum. 

For the novice in massage manipulations, pregnancy 
should constitute an absolute prohibition therefor. 

Massage (gymnastics always, of course, included) is to 
be rejected in all acute inflammations of the intestine, 
of the peritoneum, or of the intra-abdominal vessels ; in 
all forms of ulceration (round or tubercular) of the 
stomach or of the bowels ; in all cases of tumor (polypus, 

1 See Manipulations, in the section devoted to the Massage of Children. 



TREATMENT OF CONSTIPATION DUE TO ATONY 263 

sarcoma, carcinoma, etc.) within or around the alimentary 
tract. 1 

In a case of greatly enlarged spleen overlying the whole 
left half of the transverse colon, the left colic flexure, and the 
larger part of the descending colon, I directed the massage 
from the csecum upwards over the transverse colon as far as 
the right border of the enlarged spleen, making the various 
manoeuvres already described; then the hand was carried over 
into the left iliac region at the lower border of the spleen, 
and the sigmoid flexure and the beginning of the rectum were 
manipulated. The spleen itself and the parts beneath were 
left untouched. 

The result of treatment was all that could be desired. 



On Massage and Sivedish Movement Cure (Gymnastics) 

Reibmayer. Die Technik der Massage. Die Unterleibs-Mas- 

sage. 
Schreiber. Praktische Anleitung zur Behandlung durch 

Massage und methodische Muskeluebung. 
Berne, G. Le Massage. Paris, 1894. 
Ostrom, Kurre W. Massage and the Original Swedish 

Movement Cure. Philadelphia, 1890. 
Schreber. Aerztliche Zimmergymnastik. Leipzig, 1884 

(19th Edition). 
Fromm. Zimmergymnastik. Berlin, 1887. 

1 Keibmayer, Die Unterleibs-Massage. Le Marinel, loc. cit. 



CHAPTER XVIII 

TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) 

Hydrotherapy 

The measures to be considered here, having especial 
reference to their applicability in the treatment of consti- 
pation due to atony, are : 

Clysters. 
Cold tub-baths. 
Douches (showers). 
Cold compresses. 
Cold moist-frictions. 

1. Clysters. — Rectal injections, medicated and other- 
wise, are well known, as also their mode of administra- 
tion. The fountain syringe, with a bag of the capacity 
of two or three quarts, is generally the most useful and 
the most convenient instrument, as it does not require the 
intervention of a second person as is the case with the 
various other kinds of syringes. 

There is one defect, however, that is common to them 
all, namely, that the rectal point is too short. The effect 
of this is that it permits of the ampulla of the rectum 
becoming filled too quickly and overdistended, and thus a 
further and higher ingression of the fluid is prevented. 
Where this is of rather frequent occurrence, a marked 
dilatation of the pouch with atony of the rectum will 

264 



TREATMENT OF CONSTIPATION DUE TO ATONY 265 



result. A longer nozzle, about the length of the vaginal 
point (about five and a half inches), is an absolute neces- 
sity, and where such cannot be had a rectal tube will 
obviate the difficulty. 

A very important point, one not to be forgotten in our 
instructions to the patient, is that of position. The per- 
son to take the injection should place himself in the hori- 
zontal position on the bed or couch, with a pillow beneath 
the hips so as to elevate the pelvis 
and give the lower half of the 
trunk a downward inclination, 
facilitating thereby the inflow of 
the water and increasing its force. 
I have always found this satisfac- 
tory, and have never been required 





Self-acting Clysopump. 

to resort to the knee-elbow position sometimes recom- 
mended. The injection should never be taken in the 
sitting posture, as is so frequently done by women. 

For habitual constipation cold water injections have 
long been recommended, and I have myself in some few 
cases obtained very good results therewith. These injec- 
tions differ from the other and manifold clysters, in that 
they are not medicated, that the quantity of water in- 
jected is usually larger, and that the temperature of the 
same is considerably lower. 



266 CONSTIPATION IN ADULTS 

The amount of water for an injection is from one-half 
to two quarts, which, with the apparatus named and the 
position described, will readily flow in. The temperature 
of the water should be from about 80° F. to 75° F., and 
as the patient becomes accustomed thereto it is gradually 
reduced still further to 70° F., and even to 65° F. It 
should not be lowered beyond this. When water of a 
lower temperature, 65° F. to 55° F., is used, not more than 
one-half or three-fourths of a pint should be injected, as 
otherwise dangerous fluxions or congestions of the inter- 
nal organs might result. 

At the outset of the treatment if the bowel, especially 
the lower part thereof, is filled with very hard faeces, the 
water injected may have a higher temperature, 90° F. 
and even 95° F., as thereby the masses are more readily 
softened and their expulsion facilitated. 

Huhnerf autli l proceeds in this wise : He first empties 
the lower bowel with a moderate quantity of water, at a 
temperature of from 77° F. to 69° F., or, at the outset of 
the treatment, if there be much hard faecal matter, at a 
higher temperature. Following this, a larger quantity of 
water, one-half to one litre, 2 at a temperature of from 
86° F. to 77° F., is allowed to flow in slowly, and the 
patient told and coaxed to retain it as long as possible. 
Gradually, as already stated, the temperature of the water 
for the injections is lowered. 

As to the frequency with which these injections are to 
be taken, that will depend upon whether the clysters con- 

1 Dr. George Hiihnerfauth, Ueber die habitnelle Obstipation u. ihre 
Behandlung, etc., Wiesbaden, 1890. 

2 A litre = 2.1135 pints (Dunglinson's Medical Dictionary). 



TREATMENT OF CONSTIPATION DUE TO ATONY 267 

stitute an essential element of the treatment, or whether 
they are only incidental thereto. 

(a) Where they constitute an essential feature, they can 
be taken at first every day, then every other day, and, as 
the peristalsis becomes more vigorous and more active, at 
longer intervals. 

They can be taken at almost any convenient hour. 



Force Pump. 



Before arising in the morning, two hours after breakfast, 
or just before retiring at night, are perhaps the most 
suitable periods. If possible, the injection should always 
be taken at the same period of the day, as some regularity 
is also here of apparent benefit. 

In cases of great obstinacy, where the lethargy of the 
bowel amounts almost to a paralysis, a more powerful 



268 CONSTIPATION IN ADULTS 

and more effective instrument will be required. Here the 
force pump will render excellent service. 1 

If the cold injection does not prove satisfactory, we 
may avail ourselves of the powerfully stimulating action 
of rapid alternation of temperature by alternate hot and 
cold injections. A cold injection is taken, or given first 
and followed, fifteen minutes after its discharge, by a hot 
one, — temperature of the water 101° F. to 103° F. 

It is with clysters as with drugs ; persons soon become 
accustomed to them, and then they cease to be effective- 
This must be guarded against, and can be readily accom- 
plished by the variations in the temperature of the water, 
by variations in the quantity of the fluid injected, by 
having care not to distend too suddenly or to overdistend 
the ampulla of the rectum, — all in the manner already 
described. 

Moreover, we must warn against the abuse of the 
clyster. Taken every time the desire for stool arises, the 
necessity for the abdominal pressure, which, as has already 
been said, is so important an element in the act of defeca- 
tion, is done away with ; the abdominal muscles get out 
of the habit of acting in this way, and constipation 
results, or, if already present, is greatly aggravated. 2 

(b) Where clysters are only an incident in the treatment 
of constipation by massage or electricity. As we are fre- 
quently not able to obtain in the early period of treat- 
ment a sufficient discharge from the bowels by these 
measures, and as it is one of the chief rules of treatment 

1 See my paper on "Intestinal Obstruction," American Journal of the 
Medical Sciences, January, 1886. 

2 Winternitz, Hydrotherapie, Handbuch der Allgemeinen Therapie, 
Ziemssen. Beni-Barde, Nouveau Dictionnaire de Mede'cine. 



TREATMENT OF CONSTIPATION DUE TO ATONY 269 

that the use of purgatives must cease at once, we will, when- 
ever the necessity for a more thorough clearing out of the 
intestinal canal arises, i.e. when the effects of the reten- 
tion become too disagreeable for the patient to endure 
any longer, avail ourselves of the clyster to afford the 
relief required. This may be once in three or four days, 
once a week, even once in two weeks. The ordinary cool 
injection, water at the temperature of from 80° F. to 
75° F., will fully answer the purpose. 

As to the mode of action of the clyster upon the intestine, 
it may be said that it is 

1. Mechanical. — The intestine is distended by the mass of 
water injected, and the muscles thereof are thus excited to 
contraction. 

2. Thermal. — It has been demonstrated, both experimentally 
and clinically, that cold water will arouse the peristaltic move- 
ments of the intestines, and this so markedly that not infre- 
quently they can, in rather thin persons, be discerned through 
the abdominal parietes. Warm water allays peristalsis, and 
it is for this reason that constipation is so generally observed 
in persons addicted to warm injections. 1 Hot water, like cold, 
excites peristalsis, as I have already set forth elsewhere. 2 

Both these moments act upon the ultimate nerve filaments 
distributed in the mucous coat, and through them the various 
muscles are aroused to action. Moreover, by reason of the 
stimulation of the ultimate nerve filaments, of the direct 
mechanical influence of the impact of the water upon the 
tissues, and of the contraction of the muscles, the blood-vessels 
are contracted, the blood is driven forward more rapidly, the 
contracted vessels dilate, are again contracted, and thus finally 
the whole intestinal and gastric circulation is accelerated. 
A greater amount of oxygen is carried to the parts, the energy 

1 Winternitz, loc. cit. 

2 American Journal of the Medical Sciences, January, 1SS6. 



270 CONSTIPATION IN ADULTS 

of the nerve action is heightened thereb}', and, as a result, the 
physiological functions are much better performed. 

It acts upon the intestines in still another way. It has 
been shown by the investigations of Rohrig 1 that injections 
of water into the rectum increase the rapidity of the portal 
circulation and heighten the pressure in the hepatic cells. 
There is an increase in the quantity of bile secreted, and 
increase of bile means exaggeration of peristalsis. 

The methodical use of rectal injections of cool or cold 
water is more especially indicated in the cases of ha- 
bitual constipation dependent in a measure upon internal 
haemorrhoids. 

In the constipation of chronic intestinal catarrh. 

In the constipation connected with icterus. Intestinal 
irrigations, with one to two litres of water at a tempera- 
ture of 77° F. to 73° F., methodically carried out, one to 
three times a day, have, according to Krull, given most 
excellent results in jaundice. There is a rapid abatement 
of all the annoying symptoms. 2 

Small injections of very cold water, temperature 60° F. 
to 55° F., are very effective in the hyperaBsthesia of 
the rectum sometimes found associated with neurasthenia 
and hysteria. 

2. The Cold Tub-Bath (Halbbad, Winternitz). — The cold 
tub-bath is the bath in the ordinary bath-tub, with the 
water at the temperature as it flows from the hydrant, 
plus what it may gain from standing in the tub over 
night. 

It is always my direction that the water be allowed 

1 " Experimentelle Untersuchung iib. die Physiologie der Gallenabsonde- 
rung." Wiener mediz. Jahrbiicher, 1873. 

2 Mosler-KrulL Berliner Jclin. Wochenschrift, 1877. 



TREATMENT OF CONSTIPATION DUE TO ATONY 271 

to run into the tub the night before, and to stand therein 
till morning. 

In winter, the bath-room should be well heated, so 
that there may be no danger of taking cold on emerging 
from the bath. 

The cold bath should be taken daily ; the best time 
is on rising in the morning, or just before dinner (noon). 
I never advise it at night. Before getting into the tub, 
the hands and forearms, especially about the wrist, should 
be well moistened with cold water ; then the face and 
neck, and then the head. The chest (thorax) should now 
be well wetted, and in warm weather, or with persons 
who perspire very freely, also the axillae. The bath proper, 
which in summer may be of longer duration, should not 
last over a minute in winter ; very obese persons may 
prolong it to three minutes. However, summer or winter, 
it should always end before the second chill can come 
on. Whilst in the bath, and just after getting out, 
vigorous friction with a very coarse towel, or with a 
bathing-glove, or with a flesh-brush, should be made. 

For persons not accustomed to cold bathing and rather 
afraid of it, I direct that they get into the bath with the 
water at 95° F., and that then, whilst they are in it, 
the temperature be gradually reduced, by the addition 
of cold water, five degrees. After a few days, they will 
get into the bath with water at 92° F., and reduce it, 
whilst they are in, five degrees. By this method of 
gradual reduction of the initial temperature of the water, 
and a further reduction of five degrees, the system be- 
comes gradually, and still very quickly, inured and accus- 
tomed to cold water, so that in a short time the cold 



272 CONSTIPATION IN ADULTS 

bath with the water as it flows from the hydrant will 
become not alone a pleasure, but a daily necessity. 

When the indications, therefore, exist, the bath may 
be made more stimulating by the addition of salt, chloride 
of sodium (common or sea salt), to the water. (From five 
to nine pounds of salt to thirty gallons of water.) 

Its mode of action is this : The cold bath stimulates the 
whole nervous system and gives tone to it, acting as it does 
upon the ultimate nerve filaments throughout the cutaneous 
surface of the whole body, and perhaps, also, directly upon 
the cord. The process of combustion, i.e. oxygenation, is 
hastened and made more extensive ; respiration is deepened ; 
the circulation is invigorated, and all the other physiological 
functions are quickened and more perfectly performed. In this 
way the tone of the muscular system is raised, and the muscles 
aroused from their lethargic state. Furthermore, the cold 
water acts directly upon the muscles, causing them to contract, 

— clearly demonstrated by the cramp in the calves, or in the 
feet, that occasionally seizes the bather on getting into the 
cold water. The abdominal muscles are invigorated, and their 
lost tone is restored to them. By the increased combustion, 
excess of fat deposited around the intestines is consumed ; by 
the quickening of all the other functions and their more perfect 
performance, by the contraction of the muscles, any redundancy 
of tissue in the abdominal walls is taken up, reabsorbed. They 
lose their flabbiness, become firm, afford the requisite support to 
the abdominal organs, and are adequate to exercise, when called 
upon, that pressure upon the bowels which is so necessary to 
normal defecation. 

The cold bath is specially indicated in the constipation 
of neurasthenia. 

In conditions of great flabbiness of the abdominal walls, 

— pendulous belly. 



TREATMENT OF CONSTIPATION DUE TO ATONY 273 

In the constipation due to large deposits of fat in the 
mesentery and around the intestines. 

The salt bath should be advised for persons who do 
not react quickly to the cold water alone. It is of ad- 
vantage in ansemics, in cases of chlorosis, and in jaundice. 

3. The Cold Moist-Rubbing (Die Kalte Abreibung). — 
It is made in this wise : A large sheet (bed sheet) is 
folded up, placed in a bucket of cold water, and allowed 
to remain therein over night. (If it be dipped and wrung 
out of cold water several times, shortly before using, it 
will answer very well.) In the morning it is wrung out, 
unfolded, and thrown from the back over the shoulders 
of the person to be treated, like a mantilla. The assist- 
ant (a member of the family, friend, or bath attendant) 
now places his hand upon the sheet, as it lies upon the 
body, and with long, up-and-down strokes rubs the .dorsal, 
whilst the patient, grasping the various forward ends of 
the sheet, rubs the anterior surface of the body with them. 

Or it may be applied in this way : The assistant having 
wrung out the sheet holds up one corner, and, placing 
the further corner of the same side in the axilla of the 
patient, folds the sheet around him completely, and as 
smoothly as possible, from the neck down, by the corner 
which he holds. The free end coming over the still bare 
shoulder (in the axilla beneath which the further end of 
the sheet is held) is stuffed into the ring formed at the 
neck. The anterior borders are folded around the lower 
extremities and held there by them, they being brought 
together. Placing his hand upon the sheet, he now rubs 
the body with it in long up-and-down strokes, as already 
stated. 



274 



CONSTIPATION IN ADULTS 



Care must be had that all the various parts of the body 
are well rubbed, and several times each. 




Application of the Wet Sheet. (Preller.) 

The moist friction is made from three to five minutes 
(at the outset of the treatment the shorter period will 
suffice), then the wet sheet is let fall, and a dry one, ready 



TREATMENT OF CONSTIPATION DUE TO ATONY 275 

at hand, wrapped about the patient, and his body well 
dried. 

Just as for the cold bath, it is necessary that the patient 
shall well moisten his hands, forearms, face, head, and neck 
with cold water before the wet sheet is thrown over him 1 to 
guard against a possible internal fluxion that might result 
from the sudden contraction of the cutaneous capillaries. 

On rising in the morning or shortly before dinner 
(noon) are very suitable periods for this treatment. 

As to its mode of action, all that has been said of the cold 
bath will apply here. The process of combustion is accelerated, 
the respiration is deepened, and a greater quantity of oxygen 
thus carried into the body. The tonus of the vessels is elevated, 
and the circulation is invigorated. The ultimate nerve fila- 
ments are powerfully stimulated, and this stimulation is trans- 
mitted to the cord and cerebral centres, and as a consequence 
the nervous or mental equilibrium, which may have been dis- 
turbed or depressed, is restored to the normal. The result of 
all this is that the various functions are better performed, and 
greater energy imparted to the muscular system. 

In all cases where the cold tub-bath is indicated but 
cannot be had either for lack of facilities or by reason of 
disinclination of the patient, the cold moist-rubbing will 
prove an excellent and effective substitute. 

It is of great benefit in neurasthenia, in the constipa- 
tion due in a great measure to haemorrhoids, and in that 
condition described as irritable rectum. 

4. The Cold Abdominal Compress (JWeptime's Girdle). — 
Of strong towelling, forty to fifty centimetres (sixteen to 

1 As to the further reasons for this, consult Winternitz, Hydrotherapie, 
and Beni-Barde ; see especially the experiments of Brown-Sequard, Edwards. 
and Tholozan. 



■^ 



276 CONSTIPATION IN ADULTS 

twenty inches) in width (dependent upon the girth of 
the person, the longer the girth the greater the width 
required), sufficient to encircle the lower half of the trunk 
three times, is taken, and two-thirds of this placed in very 
cold water, and allowed to remain therein for some time 
(about an hour). It is then wrung out, rolled up into the 
form of a roller-bandage beginning with the dry end, and 
then swathed around the lower half of the trunk. In this 
way the moist portion of the bandage will come upon the 
body, and will be covered by the dry part thereof. The 
whole is kept in place by long tapes attached to the 
extremity of the bandage. 

The whole bandage can be covered with a covering of 
flannel, or if evaporation is to be entirely prevented, a 
piece of oiled silk or gutta-percha paper can be laid over it. 

The best time for the application of this wet compress 
is the night. I direct the patient to put it on before 
retiring at night, and to take it off in the morning before 
he gets out of bed, and to dry immediately and thoroughly 
the part where it had been applied. 

Huhnerfauth l advises that in the winter season patients 
applying the wet girdle at night should wear a flannel 
bandage around the abdomen during the day. 

The mode of action is the same, though of course limited in 
extent, as that of the other procedures already described. The 
application of the cold bandage has a strong, stimulating effect 
upon the nerve endings and the vessels, particularly in that part 
of the body which is always kept warm. The cutaneous capil- 
laries and blood-vessels are contracted, and the blood driven in 
upon the abdominal organs. A reaction, however, soon follows. 

1 Loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 217 

The bandage is soon warmed, and by reason of bad conduction 
becomes blood-warm. The water therein is converted into 
vapor, forming a layer between the skin and the bandage ; this 
stimulates the dilation of the cutaneous blood-vessels, and draws 
as it were the blood from the abdominal organs outward into 
them. In this way, the internal organs are unloaded, and any 
tendency to hyperemia or congestion relieved. 

Besides this local action it has a more general effect. The 
stimulation of the nerve endings is transmitted to the cord and 
cerebral centres, and the various organs are more vigorously 
innervated and stimulated to a better performance of physio- 
logical function. 

This effect will be in proportion to the degree of coldness of 
the bandage when applied, and to the length of time it remains 
moist. 

Where, as occasionally happens, the bandage does not warm 
sufficiently; where it causes a contraction of the blood-vessels 
only, and the reaction does not follow; where, consequently, the 
skin beneath remains pale and anaemic, — it indicates that the 
stimulus of the cold in the bandage was not sufficiently strong. 
We can remedy this, and avoid the unpleasant effects that 
might follow, by preceding the application of the girdle with 
more vigorous thermic and mechanical influences. Before the 
bandage is put on, that part of the body should be rubbed well 
with very cold water. The required reaction will then very 
soon follow the application of the wet abdominal bandage. 1 

It is indicated in the constipation of chronic gastric or 
intestinal catarrh ; in that dependent upon defective func- 
tioning of the intestinal secreting apparatus ; in the con- 
stipation connected with hepatic disturbances ; in faacal 
retention due to irritability or hyperemia of the various 
female genital organs. 

5. The Douche (Shower Bath, Fall-bader). — This has 

1 Winternitz, Handbuch der allgemeinen Therapie, loc. cit 



278 CONSTIPATION IN ADULTS 

numerous forms : The rain bath (shower bath), the circu- 
lar needle bath, the mobile fan douche, etc. 

The water used in the douche may be either cold alone 
or hot and cold alternately, and then it is called the 
Scotch douche. 

Where a properly arranged bathing or hydriatic insti- 
tute is at hand, and the patient is in a position to avail 
himself of its benefits, we can advise that he take alter- 
nately the circular needle bath and the cold rain bath for 
from one to one and one-half, or even to two minutes (as he 
gets accustomed thereto), and that this be followed by the 
application of the fan douche (Scotch, where it can be 
had) over the region of the large bowel, and more particu- 
larly over the region of the caecum and sigmoid flexure. 

In ansemics, rather feeble persons, and such as do not 
react well to cold, the douche should be preceded by a 
warming-up procedure, such as the hot-air bath of a few 
minutes' duration. This will effect an accumulation of 
sufficient warmth to enable the system to better resist 
the depressing action of the cold, and the already stimu- 
lated nervous system will tend to a quick and healthful 
reaction. 1 

Where for any reason the advantages of such an estab- 
lishment cannot be had, I advise my patients to arrange 
an abdominal douche for themselves, in this way : A piece 
of rubber tubing twenty to twenty-five inches in length is 
attached to the faucet of the hydrant, preferably in the 
bath-room if there be one, and the patient having placed 
himself upright either in the bath-tub or in an ordinary 
wash-tub, at a distance from the mouth of the tube, the 

1 Winternitz, loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 279 



stream is turned on and directed (a second person holding 
the tube) against the patient's abdomen. When it can be 
had, I have a nozzle having several small openings, some- 
thing like this, 



a 




Sprinklers. 

or round like that of a sprinkler, attached to the tube. 
Any tinsmith can furnish such a nozzle. 

Where the house is provided with a hot-water arrange- 
ment, we can, by attaching a like piece of tubing to 
the hot-water faucet, have a Scotch douche for our 
patient. 

Where for any reason this simple arrangement cannot 
be made, for want of proper facilities or what not, I have 
insisted upon my patient buying or borrowing a bath-tub, 
and having obtained it to take a douche in this wise : The 
patient lies down in the tub, and a second person (an 
assistant, friend, or member of the family) having filled 
a large pitcher with cold water allows it to flow in a 
small stream from a height of five or six feet upon the 
patient's belly, following the position of the gut. He 
can be douched in this way with hot and cold water 
alternately. 



280 CONSTIPATION IN ADULTS 

I have obtained very good results with this rather crude 
arrangement. 

I have usually found the morning hour, on rising from 
bed, when the body still retains the warmth accumulated 
therein, as the best time for the procedure when carried 
out at home. 

The douche is undoubtedly the most powerful of all the 
hydropathic measures, and great benefit will be derived 
from it, especially when employed in combination with 
other measures. 

As to its mode of action, it may be said that the douche pro- 
duces its effects by its mechanical action and its thermic influ- 
ences, and that both can be magnified or depressed according to 
the mode of production of the douche. Otherwise it acts like 
the other procedures of this method already described, only in 
a greater measure by reason of the plus influence of the impact 
or concussion. 

There is a general stimulation and elevation of energy of the 
whole cerebrospinal nervous system; the circulatory and res- 
piratory apparatus are invigorated, and the muscular system 
acquires greater force. Thus Maggiora and Vinay 1 have shown 
that a rain bath of 50° F. under a pressure of two atmospheres 
increases the work-capacity of the muscular system threefold; 
the Scotch douche, ranging from 98° F. to 53° F., doubles the 
muscular force ; even douches of tepid water produce consider- 
able effect. 

Applied to the abdomen, it acts more directly upon the parts 
concerned and soon provokes energetic and persistent peristalsis. 

It is indicated in all forms of constipation, but espe- 
cially so in the cases of dilatation of the gut or any 
section thereof, a consequence of the constipation and 
tending to perpetuate it. 

1 Blatter f. klinische Hydrotherapies January, 1892. 



TREATMENT OF CONSTIPATION DUE TO ATONY 281 

In cases of constipation with marked atony or ectasia 
of the stomach. 

If hydropathy be the method selected wherewith to 
treat our case of constipation, of the measures described 
one will be ordered in all cases, namely, clysters, and cir- 
cumstances and conditions already detailed will govern us 
in the selection of the others. Thus in a case where 
deposit of fat appears to be the real etiological factor, we 
will also prescribe the cold bath ; if this cannot be had, the 
cold wet-rubbing. In addition we will direct that twice 
or thrice weekly an abdominal douche be taken — Scotch 
douche by preference. 

Where an atony of the gut is the cause of the constipa- 
tion, or where marked dilatation has already ensued, we 
will employ by preference, in combination with the clyster, 
the douche. 

In depressed conditions, as in hypochondria or mild 
types of melancholia, the douche, preceded by the hot-air 
bath, will be the treatment ; or if not this (as when the 
appliances are not at hand, or the patient cannot avail 
himself of an institute, or if the heat, the force, are contra- 
indicated), the cold moist rubbing. 

If an intestinal catarrh be the foundation of the de- 
rangement, we will resort, in addition to the clysters, to 
the cold compress, Neptune's girdle, and to an occasional 
douche. And so on, as already set forth above. 



For a clearer understanding as to the exact meaning of 
very cold, cold, hot, the following table of Dr. Beni-Barde 
is here given. 



282 



CONSTIPATION IX ADULTS 



46° F. to 53° F. . 


. Very cold 


53° F. to 61° F. . 


. Cold 


61° F. to 68° F. . 


. Fresh 


68° F. to 78° F. . 


. Chill taken off 


78° F. to 86° F. . 


. Tempered or lukewarm 


86° F. to 104° F. . 


. Warm 


Above 104 . . . 

nfni-nitv LL TTTrr1v/-»f Vt lira riio " 


. Hot 1 

in 7iamcciim'c' Wan^VinnVi rlor A 11 iran 



Winternitz, "Hydrotherapies in Ziemssen's Handbuch der Allgemeinen 
Therapie, Vol. II., Part III. Winternitz, Die Hydrotherapie auf physio- 
logischer Grundlage, 2 vols. Beni-Barde, Manuel Medical de Hydrotherapie. 
Brouardel, P., L'Eau et les Maladies, 1892. Kriiche, A., Lehrbuch der prak- 
tischen Wasserheilkunde. Lange, Wasserkuren im Eigenen Hause. Duval, 
Traite Clinique et Pratique d'Hydrotherapie, Paris, 1888. Baruch, " The 
Uses of Water, etc." Preller, Anleitung zum Gebrauch der Wasserkur u. 
der Kiefernadelbader, Ilmenau, 1884. 



1 Nouveau Dictionnaire de Medecine, Jaccoud. 



CHAPTER XIX 

TREATMENT OF CONSTIPATION DUE TO ATONY (Continued) 

Electricity 

That with the electrical current we can, under ordinary 
conditions, provoke an evacuation of the bowels is a fact 
well attested by numerous observations. This point is 
indeed so well established that Curci 1 claims that by 
means of electricity we can readily make the differential 
diagnosis between obstipation due to atony and impaction 
of faeces, and occlusion of the bowel by intussusception 
volvulus, internal strangulation, etc., in those obscure 
cases where by reason of absence of characteristic symp- 
toms the exact condition confronting us cannot be other- 
wise made out. Whether it will suffice as a method of 
treatment for the permanent relief of atonic constipation, 
that is still a question upon which opinions differ. 

Erb, 2 from personal observation, confirms the very 
favorable reports of Benedikt, 3 Scapari, 4 Stein, 5 and 

1 " L' elettricita contro la paralisi e la paresi intestinale," 11 RaccogliU 
Med., 1877, 30. 

2 Handbuch der Electrotherapie (3 Bd. der Allgm. Therap. Ziemsseu). 
8 "Ueber d. Electr. Behandlung der Obstipation," Allg. Wien. Med. 

Zeitung, 1870, 33. 

4 "L' elettricita nella coprostasi da atonia intest.," Ann. unives., 1881. 
Febbr., p. 97. 

5 "Die farad. Behandlung- der Obstipation," etc., Centralblatt f. Nerven- 
heilkunde, 1882, No. 9. 

283 



284 CONSTIPATION IN ADULTS 

others, and recommends it as a most excellent measure 
for the relief of the derangement. Rockwell 1 holds a 
like opinion. 

Leubusher, 2 in a study of the question, reported fifteen 
cases observed by him in the Institute for Nervous and 
Mental Affections, of Professor Binswanger. Out of 
these fifteen cases, there were but four in whom the 
result was at all permanent ; that is, that the bowels 
still acted regularly three months after the cessation of 
the treatment. In two cases no result at all was ob- 
tained, and in the others the relief afforded was but 
temporary, the patients relapsing into their former con- 
stipated state upon the cessation of the electrization. 

That occasionally, even frequently, it fails altogether, 
is admitted by Erb, Rockwell, and others. 

That it is a most valuable aid to other measures, of 
this there can be no doubt. Nothnagel 3 recommends it 
combined with massage ; Huhnerf auth 4 employs it in com- 
bination with hydropathic measures, and has thus obtained 
excellent results. My own experience is confirmatory of 
this. 

As to the form of electricity best adapted to the relief of 
constipation, there is also a difference of opinion. Older 
writers, as Duchenne, Hoffmann, and others, used the fara- 
dic current only, and Erb, upon physiological grounds, 
seems to hold it to be the best. Rockwell expresses himself 

1 Med. and Surg. Electricity, B. & R., 1888. 

2 Centralblatt f. innere ^fedicin, 1887, p. 457, "Die Behandlung der chron. 
Stuhlverstopfung." 

3 Wiener mediz. Presse, loc. cit. 

4 Ueber die habituelle Obstipation u. ihre Behandlung mit Electricitat 
Massage u. Wasser, Wiesbaden, 1890. 



TREATMENT OF CONSTIPATION DUE TO ATONY 285 

very clearly upon this point : " Both the galvanic and 
faradic currents may be used, but my preference has been 
and is for the faradic. Its powerful mechanical and lim- 
ited reflex effects seem to be better adapted to restore the 
impaired irritability of the muscular coats." Leubusher, 
in the report referred to, states that he has found the 
galvanic current the more effective, and Shoemaker also 
claims better results from the galvanic than the faradic 
currents. 

There are two methods by which the electricity may be 
applied, whatever form of current be selected : 

I. The percutaneous method (where both poles are with- 
out, upon the external surface). 
II. The internal method (where one or two poles are 
within the rectum). 

These methods have a further subdivision as regards 
application. 

(a) Unipolar method (where one pole is placed over the 
seat of disease, i.e. the bowels, the other over an 
indifferent point). 

(6) Bipolar method (both poles over region or point 
affected). 

In the abdominal application of electricity the patient 
should always be in the horizontal position. 

Faradic Current 

A. Percutaneous Method. Procedure of Erb. — The 
anode 1 (large electrode 10 to 12 cm. long, 5 to 6 cm. 

1 Anode, positive pole. 



286 CONSTIPATION IN ADULTS 

broad) is placed stabile ! over the upper lumbar verte- 
bras ; the cathode 2 (medium-sized electrode, plate 5 to 
6 cm. square), labile, 3 is moved over the whole abdominal 
surface. Over the region of the caecum it is pressed in 
more deeply and firmly 4 and retained there, stabile, for a 
few moments ; it is moved over the colon, down over the 
sigmoid flexure, where it is again pressed in and held 
stabile for a few seconds. Then the electrode is moved 
in circles around the navel, and spirals or circles described 
with it over the whole length of the abdominal surface. 
Then the electrodes are placed in the opposite loins, stabile, 
and the current allowed to flow between them, with occa- 
sional reversals of current direction. 

The current should be sufficiently strong to call forth 
strong contractions of the abdominal muscles. In one 
way, however, it may be better to avoid these contrac- 
tions, as they prevent the deeper penetration of the cur- 
rent. The motor points must then be avoided. Duration 
of sitting, from three to ten minutes. 5 

In my own experience I have learnt to prefer the bipolar 
application, for the reason that I believe the desired result 
is obtained more quickly in this way than otherwise. 

The cathode (small electrode) is placed stabile over the 
caecum, and the anode moved over the tract of the ascend- 
ing, transverse, and descending colon over on to the 
sigmoid flexure, where the electrode is held for a few 

1 Stabile, when the electrode is held fixed, immovable. 

2 Cathode, negative pole. 

3 Labile, moving, when the electrode is kept moving around. 

4 Firm pressure increases the conductivity of the skin ; it is better mois- 
tened and in better apposition with the electrode. 

5 Erb, loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 287 

moments pressed down more firmly- then it is moved 
downward and inward to about the region of the annulus 
of the rectum, where it is again held stabile and firmly 
for a few moments. Whilst the anode is thus held stabile, 
the current direction is occasionally changed. This whole 
movement is repeated, beginning again at the caecum, and 
then an interval of rest allowed. (If the battery have no 
"reverse" attachment, the repetition is made with the 
poles changed.) 

Then beginning again at the caecum, the two poles, both 
labile and both stabile, are carried over the tract of the 
large bowel in this wise : The cathode is placed over the 
caecum at its lowest point, and the anode in advance of 
the former about a hand's breadth, and they are continued 
in this relation to each other throughout the whole move- 
ment. The two poles are held stabile for a moment, then 
a slight advance about two fingers' breadth slowly made 
and the poles again held stabile, and this alternation of 
movement and rest continued until the whole gut has 
been gone over with both poles. This is repeated, and 
then an interval of rest allowed. To close the sitting, the 
anode (large electrode) is placed over the lumbar vertebra 
stabile, and the cathode (small electrode) moved in circles 
around the navel, smaller, and then larger, and finally 
spirals and circles described with it the whole length of 
the abdominal surface. 

The strength of the current used : sufficient to produce 
strong contraction of the intestine at the anode. 

The current of the primary coil with rather long inter- 
ruptions is to be preferred, according to Sperling. 1 

1 Pierson-Sperling, Elektrotherapie. 



288 CONSTIPATION IN ADULTS 

The duration of the sitting, at the outset of the treat- 
ment, should not be longer than four minutes ; gradually 
it is increased in length for subsequent sittings to ten 
minutes. 

B. Internal Method. Procedure of Ero. — Later on 
(after proceeding first as above), to obtain, as he says, a 
stronger effect, Erb resorts to this procedure : A metallic 
electrode, insulated up to its olive-shaped point (anode), is 
introduced six to eight centimetres deep into the rectum. 

This, usually, causes no pain or disagreeable feeling; 
at most, when the cathode is in the rectum, a slight 
tingling, or pricking, or a feeling of heat. 

The other electrode is moved over the abdomen as 
already described above. 

. The current should be occasionally reversed (or the 
electrodes changed when the apparatus is not provided 
with the necessary contrivance therefor) so as to allow 
the cathode to act upon the rectum, i.e. more directly 
upon the bowel. 

The measure of intensity of the current is, here also, 
strong contraction of the abdominal muscles. 

Duration of sitting : three to ten minutes. 1 

De Watteville 2 proceeds in the same manner ; so also 
does Rockwell? The latter also favors the bipolar internal 
method by means of a double electrode. 

This latter procedure is only made use of with currents of 
quantity. His reason therefor is this : Induction currents of 
tension, when applied to mucous surfaces, act very mildly, both 
on the motor and sensory nerves. The parts become rapidly 

1 Loc. cit. 

2 A Practical Introduction to Medical Electricity. 8 Loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 289 




Rectal Electrodes. 





Bipolar-rectal Electrodes. 



290 CONSTIPATION IN ADULTS 

tolerant, so much so that even currents of great strength may 
be passed, and the patient remain totally unconscious thereof. 
Induction currents of quantity, however, applied to surfaces 
that offer little resistance to their passage, have a much more 
powerful influence, and are therefore to be preferred when the 
purpose is to excite muscular contraction. In order, therefore, 
that the resistance be reduced to the minimum, both poles 
should be introduced into the rectum. The parts do not be- 
come tolerant of its influence as the applications are continued. 
The use of this latter current requires the exercise of the 
greatest caution, as excessive pain is caused by strong applica- 
tions. 

In addition to the local treatment, and as often sur- 
passing it in effectiveness, Rockwell recommends general 
faradization. 1 

It consists in sponging the whole or the greater part of the 
body, first one arm, then the neck, then the thorax, then the 
abdomen, 2 with one electrode, whilst the other is held stabile 
at one of the terminal points of the body, as a plate beneath 
the buttocks (patient sitting on it 3 ), as a plate pressed or held 
against the sacrum, or as a plate on which the feet rest. 

The difficulty of the application lies in the proper regulation 
of the current necessary to stimulate fully without causing 
actual pain in the different parts over which the sponge is 
being carried; this is best learnt by experiment upon oneself. 4 

Rockwell 5 places the patient in the sitting posture upon a 
stool with his bare feet upon a copper plate attached to the 
negative pole of the battery. 

The best form of electrode that is applied over the body is a 
brass ball about one inch in diameter, and this is enveloped in 
a soft wet sponge about six inches in diameter. The moistened 
hand of the operator can be used as the labile electrode, and is 

1 Loc. cit. 

2 Pierson-Sperling, Elektrotherapie, Leipzig, 1893. 

3 Ibid. 4 De Watteville, loc. cit. 5 Loc. cit. 



TREATMENT OF CONSTIPATION DUE TO ATONY 291 

the most agreeable to the patient, and next to it is the electrode 
just described. The sponge can be folded tightly over the 
brass ball so as to make a small electrode, or loosely, so that 
almost its entire surface may be applied. 1 

The duration of the sitting should not be over ten 
minutes at the outset of the treatment, giving the abdo- 
men four minutes and distributing the remaining time 
over the other parts. Gradually the length of the sitting 
may be prolonged, and the other parts (except the neck, 
for which two minutes suffice) given equal time with the 
abdomen. 2 

As regards the strength of the faradic current to be 
used in the various methods, the views of Erb have 
already been given. Rockwell 3 says that it may be left 
to the sensations of the patient. " Whatever is borne 
without great discomfort is safe to use." 

According to Lehr, the faradic bath is of benefit in 
constipation. 4 

Galvanic Current 

A. Percutaneous Method. — The anode is placed upon 
the back over the lumbar vertebrae stabile ; the cathode, 
both stabile and labile, over the whole abdomen, making 
numerous closures and frequent reversals over the whole 
extent of the intestinal tract. 

Then the splanchnic nerves are galvanized along the 
thoracic sympathetic, thus : The anode is placed over the 

1 Rockwell, loc. cit. 2 Pierson-Sperling, loc. cit. 3 hoc. cit. 

4 " Ueber electrische Bader," Verhdl. des II. Congress, f. innere Medizin, 
Wiesbaden, 1883. Die hydro-electrischen Bader, ihre Wirkung, etc., Wies- 
baden, 1883. See also "A New Electric Bath," Gartner, Wiener klin. 
Wochenschrift, 1893, 34. 



292 CONSTIPATION IN ADULTS 

lumbar vertebras stabile, and the cathode stabile and labile 
on either side of the spine from the fifth to the twelfth 
dorsal vertebra. 

Duration of the sitting, three to five minutes. 1 

Erb, in obstinate cases, uses the galvanic current for a few 
moments as described, and follows it with faradization. 2 

B. Internal Method. — One pole is placed in the rectum 
and the other (indifferent pole) upon the abdomen. 

Rockwell teaches that with the galvanic current the 
cathode should invariably be placed within the rectum. 3 
Leubusher 4 also advocates this. Shoemaker places the 
cathode in the rectum, and the other pole is pressed 
against the perineum. 5 

The strength of the galvanic current should not exceed, 
according to Rockwell, 6 two to three milliamperes even 
when used with constant interruptions ; but when it is 
used continuously, without interruptions, one to two milli- 
amperes will amply suffice. 

Shoemaker advises that the strength of the current be 
about one milliampere, rather less than more, so that at 
the outset the patient will not feel any current at all pass- 
ing. However, in the course of fifteen or twenty seconds 
he will begin to feel the cold electrode in the rectum 
growing warmer and becoming gradually heated to the 
point of painless tolerance. 

Shock or even abrupt transitions in the strength of the 
current are prejudicial to success. 7 

1 Erb, loc. cit. 2 Ibid. 3 Loc. cit. 4 Loc. cit. 

6 Medical Bulletin, June, 1890. 

6 Bigelow, International System of Electrotherapeutics. 

7 Shoemaker, loc. cit. International System of Electrotherapeutics. 



TREATMENT OF CONSTIPATION DUE TO ATONY 293 

When currents of greater strength are used with the 
internal method, the closure x of the current must not be 
of too long duration, as otherwise an eschar might be pro- 
duced. It is better, then, to make frequent reversals, and 
to have the several closures of the current of short 
duration. 2 

Method of Boudet (de Paris). — A litre of salt water is 
first thrown into the rectum ; then the electrode, best in 
the form of a stylet in a thick rubber sound, is introduced. 
The other electrode (400 cm. square) is placed upon the 
back. Currents of ten to fifty milliamperes from five to 
twenty minutes, stabile, or (when the stronger currents 
are used) frequent reversals and interpolated pauses. 8 

Galvano-Faradization 

Erb 4 recommends very highly galvano-faradization as 
introduced into electrotherapeutics by De Watteville, a 
method of treatment in which, as the name indicates, 
both currents, the galvanic and the faradic, are sent simul- 
taneously into the body. 

De Watteville' s procedure in constipation is this : A 
very large electrode (plate) is fixed to the back, whilst 
another is made to rest first upon the umbilical region 
and then carried round the whole course of the colon. 5 
Erb places the anode upon the back and the cathode 
upon the abdomen. Strong currents are used with numer- 

1 Both poles in contact with the body and the current flowing between 
them. 

2 Rockwell, loc. cit. 

3 Progres Medical, 1887, No. 67. Erb's Handbuch, loc. cit. 

4 Erb, Handbuch der Electrotherapie. 

5 De Watteville, loc. cit. 



294 CONSTIPATION IN ADULTS 

ous voltaic alternatives. 1 When the subject is very fat, 
the electrodes should be pressed down firmly so as to 
diminish the resistance between them and the viscera. 
Duration of the sitting, eight to ten minutes. 2 
Broese 3 uses very large electrodes, 400 sq. cm., both 
for the back and the abdomen. The strength of the 
faradic current of the secondary coil is raised to its utmost, 
whilst the galvanic current is gradually increased to fifty 
or seventy-five milliamperes. Duration of sitting, usually 
seven minutes. He occasionally resorts to massage in 
combination with the electrical treatment. 



Courtade 



.4 



Instruments necessary: a large tin plate covered with 
chamois skin ; one cylindrical carbon electrode 4 cm. long 
and 8 mm. in diameter, firmly attached to one extremity of a 
semi-solid insulated conductor ; one circular carbon electrode 
4 cm. in diameter, covered with chamois skin ; a faradic bat- 
tery with two coils, one of fine, the other of coarse wire ; a gal- 
vanic battery ; an induction (influence) machine. 

His procedure is divided into two parts (a) Introductory 
treatment ; (b) Treatment proper. 

A. Introductory treatment: General franklinization. 
The patient receives a static bath, of a quarter of an 
hour's duration, with the generalized breeze and the 
application of static sparks to the abdomen. 

1 Reversal of the current by means of the commutator — the pole pre- 
viously negative becomes positive, and the previously positive becomes 
negative. 

2 De Watte ville, loc. cit. 

3 Festschrift z. Ehren d. 25 jahrig. Jubilaums des Geh. R. Prof. Dr. 
Meyer in Gottingen. Pierson-Sperling, loc. cit. 

4 Journal des Practiciens, 1896, No. 47. Journal of Electro-Therapeutics, 
April, 1897. 



TREATMENT OF CONSTIPATION DUE TO ATONY 295 

B. Treatment proper : The cylindrical carbon electrode 
is introduced into the rectum as high up as possible and 
the large (tin) plate placed over the Sigmoid flexure (if 
the trouble is supposed to be located in the caecum, it is 
placed over this). The cords are connected with the 
faradic battery, and an induced current from the coarse 
wire coil allowed to pass through for three or four minutes. 
The two electrodes are now disconnected from the faradic 
and attached to the galvanic battery and a current 
allowed to flow in ; not a continuous current, but one, 
now in the form of rapid waves, now with quick inter- 
ruptions. The waves are created by running up rapidly 
from zero to 20, to 40, M.A. and back again. The cur- 
rent is interrupted by rapidly making and breaking it. 
As to the intensity of the current, though this should 
depend in a great measure upon the sensibility of the 
patient, it should not in any case surpass 40 M.A., espe- 
cially not when interruptions are made. Though the 
carbon electrodes are less apt to produce eschars, never- 
theless a too prolonged contact should be avoided ; the 
position of the electrodes should be changed from time to 
time. It is immaterial to which pole the rectal electrode 
is first attached, for the current should be frequently 
alternated. Duration of treatment with galvanic current: 
eight to ten minutes. 

The treatment is concluded in this wise : the large (tin) 
plate is placed over the dorsal or over the lumbar vertebrae 
(according to the indications in the case) ; the rectal elec- 
trode is withdrawn, removed, and the circular carbon 
electrode attached to the pole and promenaded over the 
abdomen. The cords are now detached from the galvanic. 



296 CONSTIPATION IN ADULTS 

and connected with the faradic battery, and a current 
from the fine wire coil allowed to flow in, — this makes a 
sort of electrical friction of the abdomen. 

Three sittings per week. 

The rectal electrodes as commonly found have already 
been figured. Leubusher thinks that they are but ill 
adapted to the purpose, and prefers to use a conically 
pointed sponge electrode. I use an ordinary olive pointed 
electrode for the rectum, and externally an ordinary elec- 
trode, plate or cup, covered with absorbent cotton, and 
moistened. Absorbent cotton is by all means a much 
more desirable covering for electrodes than sponges. 

Frequency of Treatment. — Ordinarily, when the con- 
stipated state is but of a few months' duration (four to 
eight months), a sitting every other day will suffice. In 
very obstinate cases of long duration (one year and over) 
a sitting should be had every day at the outset of the 
treatment, and then, later on, as improvement manifests 
itself, a treatment every other day will be all that will be 
required. 

When the sittings are had daily, I confine myself on 
the alternate days to rather feeble currents. 

Movements of the bowels may set in already after the 
second or third sitting; at other times not until after 
very many applications. Again, with some the bowels 
will move shortly after the application, two or three hours 
or even a briefer period; with others it will be ten or 
fifteen hours after the sitting. 

The Duration of the Treatment. — The time required for 
the treatment of constipation with electricity is from two 
to six weeks. Cases have been reported where two or 



TREATMENT OF CONSTIPATION DUE TO ATONY 297 

three applications permanently relieved the patient, 1 and 
others again where it required many sittings, nineteen or 
twenty, or more, to obtain the desired effect. 2 

Though it is not the purpose here to go into the physio- 
logical action of the electric current, there is one point 
that must be mentioned here, one to which Leubusher, 
I believe, first called attention, and which is of some 
clinical importance. It is this : Leubusher observed in 
the series of cases treated by him that the intestinal secre- 
tion, which previously was seemingly deficient, was greatly 
increased by the stimulus of the current. 3 

Special Indications and Selection of Current. 

1. The constipation dependent upon chronic spinal diseases 
and chronic cerebral affections (other than those of an apo- 
plectic character), galvanic current. 

2. Constipation dependent upon cerebral apoplexies, faradic 
current. 

For other forms of constipation : 

In constipation dependent upon atony, or paralysis of the 
intestine, the faradic current. 

In constipation concomitant with neurasthenia, the faradic 
current and general faradization. 

In constipation with hysteria, and in spasmodic constipation, 
the galvanic current and central galvanization. 

In hysteria we may also resort, for the general condition, to 
franklinization in the form of bath 4 or douche, 5 a method of 
treatment with which some success has been reported. 6 Locally, 
for the constipation, the galvanic current is emplo}^ed. 

Scheme of electrical treatment of constipation due to 
atony : 

1 Rockwell, loc. cit. 4 The patient upon the insulated stool. 

2 Erb, loc. cit. 5 By means of the crown-like electrode. 

3 Loc. cit. 6 Pierson-Sperling, loc. cit. 



298 

First sitting. 

Second sitting 



CONSTIPATION IN ADULTS 



Percutaneous application (unipolar or bipolar 
method). 

Percutaneous application. 

Internal application (unipolar method), the 
time divided equally between the two forms 
of application. 
Third sitting. Internal application (unipolar method) two- 
thirds of the time. 

Percutaneous application (unipolar method), 
and so on. 

We will avail ourselves, in connection with the elec- 
trical treatment, of the benefits to be derived from a prop- 
erly regulated diet, as described above, and from dietetic 
exercise. 



CHAPTER XX 

MEDICINES 

The remedies that we can call in to our assistance are 
but few in number, the whole group of cathartics being, 
as already said, excluded. They are nux vomica and 
its alkaloid strychnina, and physostigmatis faba (Calabar 
bean), of two different groups of medicinal agents. Both 
provoke peristalsis, though their mode of so doing differs. 

Nux Vomica (Strychnos Nux-vomica). Group : excito- 

motors. 1 

Tinctura Nucis Vomicae (tincture of nux vomica). — This 
may be administered in doses of five to ten drops three 
times a day, just before meals. If there be symptoms of 
dyspepsia, especially pressure after eating, I give it after 
meals, — immediately thereafter, or from one-half to one 
hour later. I have obtained very excellent effects with 
very small doses frequently repeated, guttse i in a tea- 
spoonful of water every two hours. I generally begin 
with a small dose, guttse iii in a teaspoonful of water three 
times daily, before meals, and increase by two drops every 
other day, until the maximum dose of fifteen drops is 
reached. I then descend the scale, diminishing the dose 
by two drops every other day, until the initial dose is 

1 H. C. Wood, Therapeutics, its Principles and Practice, 1894. 

299 



300 CONSTIPATION IN ADULTS 

reached. Then the administration of the remedy is sus- 
pended, to be resumed again in two weeks or ten days, if 
the indication therefor still exist. If there be much flatu- 
lence, it will be well to combine the nux vomica with 
Fowler's solution : 

I£ Tinct. Nuc. Vomic. 3 iii 

Solut. Fowleri 3 i 

M. Sig. 

Arsenical preparations, especially the one named, have 
apparently a marked influence in inhibiting the develop- 
ment of flatus. 

Strychnina (strychninse sulphas; strychninse nitras). — 
Some prefer to administer strychnine. It may be given 
in pill form, in doses of one-sixtieth to one-thirtieth of a 
grain, three times daily, after meals. I have had very 
good results with doses of one one-hundredth of a grain, 
well triturated with sugar of milk, taken every four hours. 
If there be indigestion due to insufficiency of hydrochloric 
acid in the gastric secretion, the strychnine can be com- 
bined with the acid, thus : 

I£ Acid. Hydrochloric, dilut. 5ss 

Strychnina. Sulphat. gr. 1-^ = (^"A" P er dose) 

M. Sig. Ten drops three times daily, after meals (it can be 
given, if thought preferable for any reason, before meals). 

As a rule, it is more convenient for this class of 
patients, who generally follow their vocations as usual, to 
take their medicine three times daily ; a more frequent 
administration necessitates the carrying of the medicine, 
and that is very inconvenient. 



MEDICINES 301 

2. Physostigmatis Faba {Physostigma venenosum, Cala- 
bar bean). Group : depresso-motors. 1 

Tinctura Physostigmatis Fabae (tincture of Calabar 
bean) can be administered in doses of ten drops three 
times a day. I prefer to begin with a smaller dose, five 
drops, and gradually to reach the maximum dose of twelve 
minims three times daily. 

Extractum Physostigmatis Fabae (extract of Calabar 

bean). 

Dose (gr. ^-J) 

3, Extract. Physostigmat. Fab. grs. 1^ 
Glycerinse 3 v 

M. bene Sig. Three to six drops, three to four times daily. 

It can be given also in pill form. 

Some combine the physostigma with belladonna and 
nux vomica, 2 others with belladonna and ergot, thus : 

$ Extract. Physostigmat. Fab. gr. ± 
Extract. Belladonna. grs. ii 

Extract. Ergota. grs. xii 

M. ft. Mass. et divid. in pillul. sequal. No. VI. Sig. One 
pill at bedtime. 3 

I myself never give belladonna in this form of consti- 
pation and never combine the remedies mentioned ; I pre- 
fer to give them individually and alternately, believing 
that a better result can be thus obtained. 

Physostigmine, Syn. Eserine (alkaloid of Calabar bean), 
Physostigminae Salicylas, can be rubbed up with sugar of 

1 H. C. Wood, Therapeutics, its Principles, etc. 

2 Brunton, Text-book of Pharmacology, Therapeutics, and Materia Med- 
ica, Philadelphia, 1888. 3 Treat's Annual, 1890. 



302 CONSTIPATION IX ADULTS 

milk. The dose, according to Brunton, 1 is one-sixteenth 
to one-twelfth of a grain. Helbing, in his Modern Materia 
Medica, gives as the dose for administration one one-hun- 
dredth to one-fiftieth of a grain. 

The sulphate is used in veterinary practice only. It is there 
given hypodermatically in colics. 

Ergot has also been warmly commended for use in 
atonic constipation.' 2 Dr. Granzio reported two cases of 
atonic constipation, resulting from the prolonged abuse 
of purgative medicines, in which excellent results were 
obtained with ergot. Three doses, of ten grains each, 
were given at intervals of two hours, and were followed 
by a full and free evacuation. The next day an evacua- 
tion occurred spontaneously. The ergot was now admin- 
istered in smaller doses, and after a few days the patients 
were discharged well. 3 

It may be given alone or in combination with bella- 
donna, with Calabar bean or with mix vomica. 

Zinc Sulphate was recommended by older physicians for 
obstinate constipation. It has been used as a tonic in 
flatulence and flatulent distention of the colon. 4 

It is best administered in the form of a pill made with 
bread crumb, or it can be made into a mass with some 
indifferent extract like Gentian or Taraxacum and put into 
a capsule. Dose, two to five grains, three times a day. 
It is said to be of service in those suffering from want of 
tone, in the weak and debilitated. 

1 Loc. cit. 2 Brunton, loc. cit. 

3 El Siglo Medic, November 4, 1883. All genuine mediz. Central- Zeitung, 
May 24, 1884. New York Medical Record. 1884. 

4 Brunton, Pharmacology, Therapeutics, and Materia Medica, 1888. 



MEDICINES 303 

Case 39. Mr. Baly reported the following case to the 
London Medical Society : A young lady came under his care 
in the autumn of 1853, anaemic and of feeble constitution ; had 
been troubled with habitual constipation from childhood ; from 
the age of fifteen had constantly had recourse to large doses 
of aloetic aperients, and for many years had not had any action 
of the bowels without their aid. Latterly, she had frequently 
used injections, but these now fail frequently, and, at the present 
time, she generally obtains relief every three or four days by a 
dose of blue pill and colocynth at night, followed by an enema 
in the morning ; the latter frequently repeated. She complains 
of great debility ; inability to make exertion, mental or bodily ; 
temper irritable ; spirits depressed ; pulse feeble ; catamenia 
regular, but pale ; frequently suffers from cold extremities ; 
appetite small. When the bowels have not acted for three or 
four days, she suffers from a sense of fulness and distention of 
the abdomen; she frequently, after an evacuation, suffers for 
some hours from severe prostration. In this case he revived 
the treatment proposed by Dr. Strong in 1842, it being evident 
that the continued employment of any form of aperient would 
be hurtful. Having, as a preliminary measure, cleared out the 
bowels with a dose of blue pill and colocynth, followed by an 
enema, he ordered sulphate of zinc, five grains, bread crumb 
sufficient for a pill, to be taken three times a day immediately 
after each meal. This was continued for ten days without 
causing sickness and with decided relief to the abdominal dis- 
tention ; the appetite improved, the listlessness decreased. No 
evacuation occurred from the second day till the tenth, when the 
following was administered : Calomel, four grains, extract colo- 
cynth co., six grains; make a pill to be taken at bedtime, to 
be followed by a black draught in the morning. On the day 
following this the bowels acted spontaneously, and, from that 
time until now, nearly twelve months, have been relieved daily 
without aperients or enemata. The use of the sulphate of zinc 
was continued for three weeks, and then gradually exchanged 
for sulphate of quinine. A curious fact deserves notice in this 
case. For some time after the discontinuance of the enemata. 



3Q4 CONSTIPATION IN ADULTS 

the patient was not sensible of the action of the rectum during 
the passage of the fseces. 

Other cases were cited in support of the treatment, the 
use of which he would limit to cases dependent upon a 
want of tone. 1 

Ammonii Chloridum {Ammonium muriatieum; Chloride 
of Ammonium). — The muriate of ammonia will be 
found of much service in those cases where, the faeces con- 
tinuing hard and dry and lumpy, there is evidently a 
deficient secretion of mucus as a result of glandular 
atony (from prolonged pressure of the accumulated faeces 
upon the mucous membrane, from general debility), or 
even perhaps of glandular atrophy, to a certain extent 
(from protracted intestinal disease, as enteric fever, acute 
or chronic inflammations). 

That it stimulates the action of the muciparous follicles 
of the mucous membrane is a matter of long observation 
as regards the bronchial mucous membrane, and that it 
acts in the same way upon the intestinal mucous mem- 
brane, I can affirm from my own clinical observation. 
Brunton makes mention of this action in his Pharma- 
cology and Therapeutics. 2 

Dose and Administration. — It may be given in doses of 
five to ten grains three times a day. It is best adminis- 
tered in the intervals between the meals. 

It can be given in the form of a tablet, or in powder 
to be dissolved in water or milk. 

1 Lancet (London), 1854, Vol. II., p. 381. 

2 A Text-book of Pharmacology, Therapeutics, and Materia Medica, by 
T. Lauder Brunton, M.D., etc., Philadelphia, 1888. 



CHAPTER XXI 

I EFFECTS OF TREATMENT. II. COMPLICATION 

I. Effects of Treatment. — These various methods of 
treatment can be employed singly or combined, as already 
indicated. However, it will be found, I believe, that a 
combination of two or more of these methods will greatly 
enhance the efficacy of our efforts. Thus we may com- 
bine massage with electricity as recommended by Noth- 
nagel, 1 or with electricity and medication; or massage 
and hydropathy, adding thereto the administration of 
certain medicines as may appear to us indicated. We 
may combine hydropathy with electricity, or with medica- 
tion, or with electricity and medication. No doubt, in 
many instances, we will be governed in our selection of 
the method or methods of treatment by the surroundings 
and conditions in life of the patient. Much, also, will 
undoubtedly depend upon the familiarity of the physician 
with one or the other plans of treatment, or his ignorance 
of them; this last factor should be eliminated. The phy- 
sician should be acquainted, and equally well acquainted, 
with all the mechanical measures employed, in so far, at 
least, as the treatment of constipation is concerned. 

No matter what plan of treatment we select, this one 
important fact must always be borne in mind : that the 

1 Wiener mediz. Presse, loc. cit. 
305 



306 CONSTIPATION IN ADULTS 

dietary regulations and the rules as to exercise are indis- 
pensable to success. In fact, we may, with these alone, 
not infrequently achieve astonishing results. I have seen 
quite a number of cases of constipation of long standing 
that presented themselves at the dispensary completely 
cured by diet and exercise alone. By means of these vari- 
ous regulations and measures we will be able to restore 
to the intestinal muscles their lost vigor ; we will be able 
to reduce dilated or dilated and hypertrophic intestines to 
their normal calibre, or nearly so. 

We will be able to overcome the unpleasant head symp- 
toms frequently produced by constipation and already de- 
scribed above. In this respect massage of the abdomen, 
with faradization of the head and nucha, will prove of the 
greatest benefit. Even before we have succeeded in re- 
storing the normal intestinal function, we may have 
effected a disappearance of the head symptoms, as I have 
seen in a number of instances, and for which relief alone 
patients are very grateful. 

II. Complications. — In a number of cases of atonic 
constipation I have discovered a marked atony of the 
stomach. 

This can be recognized by the splashing sound (platschern) 
obtained on palpating the stomach from the epigastrium down- 
ward, and from the cardia to the pylorus. It may also be 
obtained by shaking the patient from side to side. In severe 
atony the region of splashing sound extends as far down as the 
navel. 

This is a complication that is exceedingly troublesome, 
as it interferes very much with the treatment, in so far 
that the dietary regulations required for the one are diamet- 



I. EFFECTS OF TREATMENT. II. COMPLICATION 307 

rically the opposite of those necessary for the other. My 
plan of treatment here is to secure first the regular action 
of the bowels, not paying any attention to the condition 
of the stomach in the regulation of the diet, but of course 
treating its atony by massage, electricity, hydropathy, etc. 
Then, when the bowels are acting fairly well, the dietary 
regulations requisite for the relief of the stomach (and 
without which much cannot be accomplished) are pre- 
scribed and enforced. 



CHAPTER XXII 

TREATMENT OF CONDITIONS RELATED TO ATONY 

I. Ileus ; with special reference to the forms named in 
the chapter, " Consequences of Constipation." For illus- 
tration, see Case 25. Most frequently seen in old people. 

If the rectum be loaded, the first step will be to empty this 
by means of the finger or scoop, if the faecal matter be very 
hard ; if not, by the use of rectal injections, cold or hot. 

When this has been accomplished, or if the rectum be 
empty, the accumulation being located higher up, we will 
resort to large injections, allowing a quart of water, at a 
temperature of 80° F. to 90° F., to flow in at a time. 
Where there is much flatus, as indicated by the marked 
tympanitis, we will add to the water either spirits of tur- 
pentine (3 i to the quart of water) or milk of assafcetida 1 
(3 ii-iii to the quart of water). These two agents I have 
found most effective for the removal of flatus. 

For the administration of these injections the patient 
lies down upon his back upon the bed or couch, a pillow 
or two is placed beneath the hips, so as to give the lower 
half of the trunk the form of an inclined plane with the 
downward inclination to the diaphragm, and the reservoir 
is elevated to a good height, 2 — three or four feet, — so 

1 Made from the fresh gum and not with the exsiccated powder resorted 
to so frequently by apothecaries. 

2 There need be no fear of injury from a reasonable amount of pressure. 
This is clearly demonstrated by the investigations of R. E. Muller, "Entero- 

308 



TREATMENT OF CONDITIONS RELATED TO ATONY 309 

as to obtain sufficient force to break down the impacted 
and obstructing mass. We can add still further to the 
effectiveness of the clyster by increasing the length of the 
rectal point of the syringe (which are all too short, as 
has already been said) by means of an O'Beirne rectal 
tube or a section of a stomach tube. 

The patient should be persuaded, coaxed, or even 
begged to retain the injection as long as possible, so 
that it may exercise its softening and thinning action 
upon the indurated mass to the largest extent. 

The injections should be repeated at intervals of three 
or four hours. When the accumulation is not very large, 
the ileus being rather of the paralytic form described, we 
may give two or three injections with the water at a 
higher and lower temperature alternately, as already set 
forth, at intervals of fifteen to thirty minutes, and then 
rest for three or four hours. 1 

In the intervals we may administer small doses of olive 
oil, 3 i-ii every two hours, with an equal quantity of 
glycerine or honey. (This makes the oil more palatable 
and more readily taken.) 

In the place of water we may use oil for the injections, 
according to the method of Fleiner. 2 



clyses in the Summer Diarrhoea of Children, etc., with the Results of Labo- 
ratory Investigations," Therapeutic Gazette, 1893. 

1 This procedure can and should be resorted to in obstruction from intus- 
susception volvulus, etc., upon the basis first laid down in my paper on this 
subject in the American Journal of the Medical Sciences, January, 1886, and 
reiterated in an editorial in the Archives of Pediatrics, November, 189f>. 
namely, either that the injection will quickly relieve the obstruction or its 
failure be a positive indication that operative interference is necessary and 
should not be delayed. 

2 See chapter, " Oil Injections." 



310 CONSTIPATION IN ADULTS 

We may further aid our efforts, and add to the vigor 
of the peristaltic movement excited, by the administration 
of strychnine, preferably in small doses, or the tincture of 
nux vomica, two drops every one or two hours. 

II. Intestinal Paralysis, due to the exhaustion of mus- 
cular vigor in the large bowel by reason of over-excita- 
tion or over-stimulation by strong cathartics. 1 

In persons of constipated habit, we may have at times 
a paralysis of the intestinal tract come on very suddenly. 
The bowels refuse to act. The remedies which have usually 
provoked evacuation are inefficient, even in increased doses. 
Still more powerful agents are equally without effect. The 
condition resembles very much intestinal obstruction. 2 

Treatment. — Electricity, external or internal method, 
or both combined. 

Hydropathic measures : the douche to the abdomen ; the 
general rain-bath ; the clysters, hot or cold. 

Medication, addressed to the nervous system, or to both 
the nervous and muscular system ; nux vomica or strych- 
nine or physostigma, alone, or combined with ergot or 
with other agents having a similar action ; I have some- 
times given it with quinia. In the condition described 
(or in analogous conditions from chronic central lesions) 
I like to give the strychnine in small, but frequently 
repeated, doses, one one-hundred and twentieth to one 
one-hundredth of a grain, well rubbed up with sugar of 
milk, every four hours. 3 

1 Other forms have been already referred to. 

2 See Des Pseudo-Etranglements, by Dr. Henri Henrot, Paris, 1865. 
Treves, loc. cit. "Pseudo-Intestinal Obstruction," by H. Illoway, M.D., 
Medical News (Philadelphia), August 28, 1886. Rosenheim, loc. cit. 

3 The trituration must be very thorough. 



TREATMENT OF CONDITIONS RELATED TO ATONY 311 

III. Atony of the Rectum. Atony of the Pouch of the 
Rectum} — It has already been stated that the various 
segments of the large bowel can be distended as a result 
of atonic constipation, and that the rectum forms no ex- 
ception thereto. The whole rectum is then involved in 
the distention, and usually the parts above it as well. 

Under the term atony of the rectum, however, we have 
described to us a condition wherein the ampulla of the 
rectum alone is distended, the rest of the rectum, as also 
the parts beyond, retaining their normal character. 

Constipation of an obstinate character is a feature of 
this condition. 

As to the causes of this dilatation, I may say that I 
am not of the opinion that the most frequent etiological 
factor is a neglect of the calls of nature. I do not be- 
lieve that ordinarily, even with a marked degree of atony, 
the faeces, once so low down, can be held there, and this 
for reasons already set forth in the chapter on the physi- 
ology of defecation. The most frequent causes, in my 
opinion, are such pathological conditions of the rectum 
as tend to make defecation exceedingly painful, strong 
contractions of the sphincter being then provoked and 
the faeces forcibly held back. These conditions are : 

Fissure of the anus. 

Haemorrhoids. 

Hyperaesthesia of the lowest segment of the rectum. 

Painful conditions of the genito-urinary tract. 

It may also result as a consequence of the great debility 

1 See the various works on Diseases of the Rectum, Kelsey, Mathews. 
Cripps, Van Buren. In most works under the head of ''Impacted Faces." 



312 CONSTIPATION IN ADULTS 

following protracted exhausting diseases, as typhoid fever, 
long-continued remittent fever, etc., when the patient does 
not possess sufficient strength to force inspissated and 
scybalous faeces through the sphincter. Here, the rather 
concentrated character of the aliment, containing but very 
little residual matter, is also, no doubt, an important factor. 
Furthermore, the greatly lowered nervous irritability, and 
the fact that such patients pass most of their time in the 
lying or sitting posture, greatly favor the retention and 
the accumulation of faeces at this point. 

An anaesthetic condition of the rectum as may occasion- 
ally be met with in the neurasthenic, and more frequently 
in the hypochondriac and the melancholic, tends to its 
development. 

It is very much favored by the constant use of tepid 
or warm injections to which so many persons, especially 
females, are addicted. 

Old age, with its debility, its obtunded sensibilities, and 
the tendency to sit or lie down a great part of the time, 
favors the production of atony of the rectum. 

It can thus occur at all periods of life, and in persons 
of every condition. Most commonly, however, it is met 
with in delicate females with lax muscular fibre, and in 
persons of very advanced age. It is said to be met with 
in delicate children. 

The dilatation of the ampulla may reach an enormous 
extent. Generally the pouch will be found to contain 
large masses of faeces indurated to stony hardness. 

The pressure made upon the mucous membrane of the 
rectum may set up a catarrhal irritation with the charac- 
teristic discharge. 



TREATMENT OF CONDITIONS RELATED TO ATONY 313 

The symptoms of this condition have especial reference 
to the rectum. A sense of fulness or weight therein, with 
sometimes a sensation as if a weight were pressing down 
the parts. Frequent desire to go to stool which, when 
gratified, results in the discharge of a few small, hard, 
scybala, or of a little fluid focal matter which may lead 
us to a wrong diagnosis. Pain, due to spasm of the 
sphincter, frequently attends the stool. 

With these we may have symptoms of irritation of the 
various organs of the genito-urinary tract, excited by the 
pressure made upon them by the indurated and hardened 
faecal mass. 

Sometimes we have only constipation, without any other 
especial manifestation to indicate to us the seat of the 
difficulty. 

Examination of the rectum with the finger will disclose 
the presence of a large quantity of hard, firmly packed 
faeces, and when this has been evacuated, the finger will 
sweep about in a large, sometimes immense, pocket, as 
it were. 

Examining with the speculum, the pocket will be found 
filled sometimes, with enlarged folds of loose mucous mem- 
brane which have a tendency to pass downward, with the 
efforts at stool, between the two sphincters, and thus 
narrow and even block up the exit against the faecal bolus. 

For the relief of this condition we will firstly remove 
or render innocuous the cause or causes that have pro- 
duced it. If fissure of the anus be present, we will incise 
it as advocated now by the majority of writers, or we 
may treat it with forcible dilatation. Haemorrhoids will 
receive the proper attention ; etc. 



314 CONSTIPATION IX ADULTS 

We will cleanse the rectum thoroughly of all scybala 
or faecal accumulations. We will then see to it that the 
patient has daily a full and free evacuation. To accom- 
plish this we may resort to the rectal injection of glyce- 
rine 3 ss-i, or to the glycerine suppository (which I do not 
think as effective), or to the injection of a small quantity 
of very cold water. 1 This latter has this additionally in 
its favor, that it stimulates both nerve and muscle of the 
part, and thus tends to invigorate it. It will also aid in 
dispelling the turgidity or congestion which is almost 
always present in atony of the rectum. 

To this may be added the cold douche to the abdomen 
or the general rain-bath. We will further tone up the 
general abdominal vigor by massage, and for the special 
condition under consideration, we will " beat the sacrum," 
as already described. 2 

We can employ electricity both percutaneously and 
internally. The faradic current should have the prefer- 
ence. 

In addition to all this, we will resort to the proper 
medication to give tone to the system. We may give nux 
vomica in extract, one-half to one grain in a pill once daily, 
or after the fashion already described. Strychnine is, I 
think, specially indicated, alternating with physostigma 
where the condition seems to require it. Bark (compound 
tincture of cinchona) with nux vomica or strychnine or the 
hypophosphites with strychnine will be given, according 
to the indications. 

With these measures all can be accomplished that is 
requisite, and astringent injections and the use of purga- 

1 See section on "Hydrotherapy." 2 See section on " Massage." 



TREATMENT OF CONDITIONS RELATED TO ATONY 315 

tives, as were formerly advocated, can generally be dis- 
pensed with. 



Bretonneau recommended as a local injection to induce con- 
traction of the part : 

t> Extract. Rhatanise (Kramerise) Z ii 
Spirit. Vin. Rectihcat. 3 v 

Aqu. Pura. § iv Misc. 

This prescription is also highly commended by Trousseau 1 
for the treatment of anal fissure. 

Bodenhammer claimed good results from 

5- Acid. Tannic. 3 i 

Claret Wine 3 iv Misc. 

He has also used with success decoctions of white-oak bark 
and alum, as also the decoction of galls. 

With these astringent injections the use of purgatives, as 
already mentioned above, is combined. Bodenhammer gives a 
pill composed as follows : 

^ Extract. Aloe 3 ss 

Extract. Nuc. Vomic. 3 i 

Extract. Hyosciam. grs. xv 

Ferr. Sulphat. grs. x 

Ole. Caryophyll. gtt. v 
M. ft. pillul. No. XXX. Sig. Take one at dinner or at 
bedtime. 

Van Buren prescribed this pill : 

I£ Ferr. Sulphat. Exsiccat. 

Quinia. Sulphat. aa ^ ii 

Extract. Nuc. Vomic. 
Extract. Aloe aa grs. xii 

Misc. ft. pillul. No. XL. Sig. One pill three times a day. 
1 Clinical Lectures. 



316 CONSTIPATION IN ADULTS 

Or a prescription, as follows, is given : 

5, Extract. Aloe 

Extract. Hyosciam. aa 3 i 

Extract. Nuc. Atomic. grs. iv 

Ole. Anis. gtt. iv 

M. S. A. et ft. pillul. No. LX. Sig. One pill after dinner. 

Where there is too great a redundancy of the mucous 
membrane of the pouch so that, in the act of defecation, 
its folds obstruct the passage, an operative procedure may 
have to be resorted to. 1 

Atony of the whole intestinal tract may result from 
atony of the rectum. 2 

1 Kelsey, " The Surgical Treatment of Constipation," New York Medical 
Journal, May 16, 1896. 

2 " Atony of the Rectal Pouch," etc., by William Bodenhammer, M.D., 
New York Medical Record, April 6, 1889. Van Buren, Lectures on the Dis- 
eases of the Rectum, " Atony of the Rectum," 1882. Mathews, loc. cit., 
" Impaction of Faeces." Kelsey, The Diseases of the Rectum. Curling, On 
the Diseases of the Rectum. Trousseau, A., Gazette Medicale (de Paris), 
Tome VTIL, No. 36, 1810. 



CHAPTER XXIII 

TREATMENT OF ATONY OF THE INTESTINE DEPENDENT 
UPON MORBID PROCESSES 

I. Constipation dependent upon Chronic Intestinal 

Catarrh 

Constipation is frequently due to a catarrh of the large 
bowel. In fact, it is laid down as one of the characteristic 
features of chronic catarrh t)f this section of the intestinal 
tract that the patients are constipated the major part of 
the time. This constipation alternates with diarrhoea, in 
this wise : the patient may go three or four days without 
an evacuation, and then a diarrhoea will supervene which 
may last a whole day or cease with two or three very thin 
discharges following each other in rapid succession. An 
examination of these discharges will show undigested 
matter in considerable quantity, and will also disclose to 
us (by the odor) that fermentation or putrefactive pro- 
cesses have therein developed. 

The treatment of this form of constipation is in reality 
the treatment of the intestinal catarrh. 

I. Of the utmost importance is the regulation of the 
diet. All vegetables and all raw fruits are strictly pro- 
hibited ; all meats, whether fish or flesh, are banished 
from the list of edibles. The diet list is made up of the 
following articles : rice, barley, farina, fine ground hominy, 

317 



318 CONSTIPATION IN ADULTS 

sago, cornmeal, oatmeal. Occasionally, vermicelli or grated 
noodles l are well borne and can be permitted. 

Cocoa, milk, black tea. 

Chocolate can be eaten. 

A little syrup (maple or cane) or honey, as an addition 
to the farinaceous articles, may generally be permitted. 

All food must be boiled or baked (with the addition of 
a minimum quantity of sweet butter). Anything fried is 
absolutely hurtful, and must therefore be strictly forbidden. 

Xo alcoholic liquor of any kind. 

Later on. as the case progresses favorably, a soft-boiled, 
or a hard-boiled, cold, (so-called railroad) egg can be per- 
mitted. Meats and fish are not allowed until the patient 
has fully recovered. 

II. Massage. — At the outset, the mild introductory 
emeurage and manipulations 3 and 4 of Group (7, gently 
made. Later on these are executed more vigorously, and 
the various other manipulations as the case progresses. 

III. Hydrotherapeutic Measures. — First of all the large 
clyster to effect a daily evacuation, and thus prevent accu- 
mulation of faecal matter and subsequent irritation of the 
intestinal mucous membrane. 

The injection has also a curative effect upon the irri- 
tated intestinal mucous membrane, and therefore can be 
made, if desired, of decoctions of aromatic herbs, as chamo- 
mile or peppermint — the latter has a remarkably soothing 
and quieting effect upon the bowels. Or strong infusions 
of these herbs may be added to the cold water. 

The cold moist-abdominal bandage applied as described. 

IV. Medication. — I have generally found that these 

1 See formulary. 



TREATMENT OF ATONY OF THE INTESTINE 319 

measures, of which I consider the dietary regulations as of 
the first and foremost importance, succeed in relieving 
the ailment without any medication. Sometimes I have 
thought it advisable to prescribe small doses of phosphate 
of soda, where there seemed to be an insufficient quantity 
of lubricating mucus secreted. When too much was 
secreted, I have found the decoction of cortex simaruba 
of the greatest value in modifying it, and bringing it 
within normal limits. There is, for this purpose, nothing 
superior to it in the pharmacopoeia. 

II. Atony from Morbid Processes Elsewhere 

1. Neurasthenia (Nervous Exhaustion). — As a result 
of the physical depression characteristic of neurasthenia, 
we have, not infrequently, constipation, alone or com- 
bined with other dyspeptic phenomena, as one of the 
manifestations. 

In the diagnosis of neurasthenia, this very important 
point must be borne in mind, that constipation or indiges- 
tion may give rise to symptoms much like those found in 
neurasthenia, and may thus lead to error. 

The treatment here must be essentially that of the 
neurasthenia. With its relief or improvement the con- 
stipation will also be improved, or disappear. 

We may send our patient to the mountains. 

We may advise a sea voyage. 1 

But best of all 2 we will institute a hydropathic treat- 
ment which is superior to other methods of treatment in 
the permanency of its benefits. 

1 Osier, Practice of Medicine, 1892. 

2 Lowenfeld, Pathologie u. Therapie d. Neurasthenie u. Hysterie, 1893. 



320 CONSTIPATION IN ADULTS 

The measures particularly indicated here are : 

The cold moist-rubbing. 

The cold tub-bath. 

If treatment can be had in a hydropathic institute : 

The hot-air bath, of short duration, followed by 

The cold rain-bath, or by 

The cold fan-douche, or the alternately hot and cold fan- 
douche. 1 It will be best, especially where the depression 
is very marked, to begin with the cold moist-rubbing, 
having the temperature of the water in which the sheet 
is soaked at 90° F. to 85° F., and gradually reduce it, in the 
course of the period in which the patients are under treat- 
ment, to 75° F., to 70° F. Then we may substitute for it, 
for a time, the cold tub-bath or, where the patient can avail 
himself of the advantages of a hydropathic institution, the 
hot-air bath and douches as described. 

Sea bathing is beneficial. 

General massage, including the abdomen, may be re- 
sorted to. 

We may employ electricity, galvanic or faradic. Gal- 
vanization of the head is apparently of much benefit. In 
very apathetic individuals general faradization will be 
useful. 

We will carefully regulate the diet. It should consist 
mainly of milk, meat, and eggs. Milk is a very important 
factor; one and one-half to two quarts per day should be 
taken. All alimentary articles, tending to produce flatu- 
lence, which is doubly distressing and doubly irritating 
to the neurasthenic and tends to make the constipation 
more obstinate, must be avoided. 

1 See chapter on " Hydrotherapy." 



TREATMENT OF ATONY OF THE INTESTINE 321 

As to the special feature that concerns us here, the 
constipation, we will direct in the diet of the patient cer- 
tain articles which favor peristalsis: buttermilk, two or 
three glasses per day (replacing the same quantity of other 
milk). This I have found especially beneficial. Then the 
fruits: baked apples, apples baked in syrup, prunes, etc., 
as described. 

In the course of the hydropathic treatment we will have 
the fan-douche directed particularly to the abdomen, to 
the tract of the large bowel. We will resort to large 
injections of water, as already described. 

We can employ the electrical current as already de- 
scribed above. 

It may become necessary in the course of treatment, 
either for the purpose of securing a more thorough empty- 
ing of the bowels, or for the general revulsive effect upon 
the abdominal organs, to resort to a purgative. A com- 
pound cathartic pill, U. S. P., one of the various aloetic 
pills, or, if the bitter taste be not objectionable, the 
mixture described in the formulary as a " tonic laxative," 
one teaspoonful every three or four hours until the desired 
effect is obtained, can be directed. 

In the neurasthenia of sexual origin, with persistent irrita- 
bility of the sexual organs, we will resort, in the male, in addi- 
tion to the measures already described, to the psychrophore 
(Kiihlsonde, cooling sound), described in detail further on. In 
women, I have derived marked benefit from the wet pack as 
employed by me in the treatment of summer complaint. 1 

A sheet is wrung thoroughly out of cold water ; the patient, 

1 "Summer Complaint," a clinical contribution, etc.. New York Medical 
Journal, 1892. 



322 CONSTIPATION IN ADULTS 

naked, is wrapped therein, and then covered with blankets. As 
soon as the sheet is warm, it is removed, and a fresh one 
applied. This is continued for two hours, during which time 
from four to six sheets are used, — more in summer, less in 
winter. In the cold months, the room must be thoroughly 
warmed. 

I have also, at times, applied the wet sheet folded so as to 
reach from about the upper border of the liver to the knees. 1 

The administration of some tonic, as strychnine with 
bark, strychnine with acid, strychnine with hypophosphites, 
according to the particular indications presented, will add 
efficacy to our other measures. 

2. Debility after Protracted Maladies. — The general 
debility, consequent upon long febrile processes, as typhoid 
fever, remittent or intermittent fever, may involve, to a 
marked degree, the intestinal tract ; and constipation, some- 
times very obstinate, results. 

It is, however, of but little importance otherwise. As 
the general system gains in vigor, the bowels become 
stronger and more active. To secure their action mean- 
while, we can resort to electricity, which is especially 
indicated for the permanency of its benefits ; to the large 
clyster ; to the injection of oil; 2 to the glycerine injection 
or suppository ; occasionally to an aloetic pill ; to a dose 
of the compound rhubarb powder or other mild and stimu- 
lating cathartic. I have obtained very good results with 
the preparations of malt regularly administered, both as 
to tonic and laxative effects. 

3. Disease of the Heart. — In the course of organic disease 
of the heart, when the normal functioning thereof becomes 

1 For further details, see Beard, Nervous Exhaustion, 1888. Lowenfeld, 
loc. cit. 2 See chapter "Oil Injections." 



TREATMENT OF ATONY OF THE INTESTINE 323 

impaired, a state of congestion of the whole intestinal tract may 
supervene, and constipation result. 1 This constipation is not 
really due to atony, but rather to change in the intestinal tissues, 
and to insufficient oxygenation of the blood. 

For the relief of the constipation we will make use, for reasons 
known to all, of the hydragogue cathartics ; of the compound 
powder of jalap ; of the compound infusion of senna ; of epsom 
salts, etc. ; or we may resort to the active mineral waters, as 
Hunyadi Janos, Friedrichshall, or Pullna. 

At the same time we will attend to the heart, which will also 
be greatly benefited by our hydragogue cathartics properly and 
discreetly used. 

1 Walshe, Walter Hayle, Diseases of the Heart, 1862. Striimpel, Text- 
book of Medicine. 



CHAPTER XXIV 

TREATMENT OF SPASTIC CONSTIPATION; ENTEROSPASM 

It is the general experience that the measures, so fruit- 
ful of good in atonic constipation, are of no avail when 
the retention of the feces is due to a spasmodic contrac- 
tion of the intestinal muscle. 

The indications for treatment here are twofold: 

First. The relief of the spasm. 

Second. The removal of the cause that provokes it. 

I. Belladonna. — For the relief of the spasmodic state, 
belladonna is the remedy par excellence. Trousseau 1 ex- 
tols it highly, and it is, undoubtedly, in the constipation 
dependent upon enterospasm, that it achieves its greatest 
successes. 2 

It may be given in the form of the tincture, guttse 
5-10 every four hours (about three or four doses per 
day). Rosenheim gives gtt. x per day. It may be given 
as extract in pills one-sixth to one-fourth of a grain, three 
or four times daily. 3 

^ Extract. Belladonna. (English) grs. ii 
Extract. Gentian. 

Extract. Taraxac. aa grs. iv-vi 

M. ft. Mass. et divicl. in pillul. sequal. No. VIII-XII. 

1 Trousseau, Clinical Lectures. Translated, Philadelphia, 1873. 

2 Phillips, Materia Medica and Therapeutics. H. C. Wood, loc. cit. 

3 I have found this to be a sufficient dose when the English extract is used. 

324 



TREATMENT OF SPASTIC CONSTIPATION 325 

Trousseau 1 prescribed the following pill : 

^ Pulv. Folia. Belladonna. 

Extract. Belladonna. aa 0.01 = (gr. £). 

M. make one pill. 

The directions are: "One of the pills is taken, by pref- 
erence, fasting in the morning, on an empty stomach. 
The number of pills may be increased from one daily to 
two daily within the first five or six days; they ought 
seldom to exceed four or five in the course of the twenty- 
four hours. Whatsoever number of pills are taken, they 
ought always to be taken at one time." 2 

I have myself made use of this formula, ordering the 
pills to be taken in accordance with the directions above 
given, and have always been very well satisfied with the 
results obtained therefrom. 

It can be ordered in the form of a suppository with 
Oleum Theobromce : 

fy Extract. Belladonna. (English) gr. i-i 
Ole. Theobroma. 3 i 

M. ft. Suppository No. I. 
One to be introduced into the rectum night and morning. 

For suppositories it is perhaps better to prescribe the 
alkaloid atropia; for greater safety, and perhaps even 
greater effectiveness, a little morphia may be added : 

$ Atropia. Sulphat. gr. -^ 

Morphia. Sulphat. gr. J- 
Ole. Theobroma. 3 ss 

M. ft. Suppository No. I. Sig. Introduce one at bedtime. 

1 Loc. cit. 

2 Trousseau, Clinical Lectures, Philadelphia Edition, Vol. II., p. 493. 



326 CONSTIPATION IN ADULTS 

I have found it advantageous to combine with the in- 
ternal administration of belladonna, and more especially 
when it is directed in the form of suppositories, the exter- 
nal application thereof. I prescribe for this purpose the 
unguentum belladonna?, and direct that a piece about the 
size of a pea or white bean be rubbed in over a section of 
the large gut morning and evening, varying the locality 
each application. 

In this way a much quicker effect is obtained than with 
the internal administration alone. 

Hyosciamus, belonging with belladonna to the same 
group of remedies, is also said to be useful in relieving 
enterospasm. It may be given in the form of tincture, 
gtt. v to xv every three or four hours (three or four times 
daily), or as extract, in pill form, from one-half to one or 
two grains every three or four hours. 

It may be combined with belladonna, a smaller dose of 
each of these remedies being then given. 

It has been recommended by some 1 to combine a mild 
laxative with the antispasmodic. When this is done, but 
the mildest of purgatives should be used, and in very 
small doses : extract of taraxacum, extract of rhubarb, 
extract of cascara sagrada, extract of rhamnus frangula, 
extract of butternut (Juglans cinerea). Occasionally very 
small doses of the compound extract of colocynth, one- 
twenty-fifth to one-thirtieth of a grain, may be given 
with the belladonna to great advantage. 

The minute doses of the purgative correct the abnormal 
peristalsis, and thus, with the antispasmodic, relieve the 
enterospasm and the tendencies thereto. 

1 H. C. Wood, loc. cit. 



TREATMENT OF SPASTIC CONSTIPATION 327 

Valerian, Assafcetida. — These remedies will be of ad- 
vantage in pronounced neurasthenic and hysterical cases. 

The valerian can be given as the simple tincture of 
valerian or as the ethereal tincture, in doses of fifteen to 
thirty drops every three hours. I prefer to give it in the 
form of valerianate of zinc. Various elegant elixirs of 
valerianate of zinc are made, and I have used them with 
great benefit in neurasthenic cases, the remedy combining 
tonic and antispasmodic properties. 

The assafcetida is best in the distinctly hysterical cases. 
It must then be given in large doses, ten grains four times 
a day. 1 It is best given in pill form. 

Oil. — Fleiner recommends as sole treatment the injec- 
tion of oil. For details see the special chapter further on. 

If there be much pain with the spasm, we will relieve the 
same by the administration of opium in some form, alone or in 
combination with the belladonna. I generally prefer the sup- 
pository of atropia and morphia (the latter, of course, in larger 
doses than in the formula given above, from one-fourth to one- 
third and even one-half a grain per suppository), as giving 
better results and with less disturbance to the general economy 
than any other mode of administration. 

If opium be for any reason contraindicated, we may give 
camphor with our belladonna, or we may resort to sulphuric 
ether. Hoffmann's anodyne is a convenient form of adminis- 
tering the latter. 

Where there has been a long retention of faeces, I have occa- 
sionally found a pill of morphia and belladonna, with minimal 
doses of colocynth (compound extract) or of podophyllin, one- 
thirtieth of a grain, to afford rapid relief. 

It may be necessary to provoke a rapid evacuation of the 

1 Dr. Louis Stronieyer, Erfahrungen iiber Lokal-Neurosen, Hannover, 
1873. 



328 CONSTIPATION IN ADULTS 

bowels. This we will effect by means of injections of very 
warm water (90° F. to 100° F.), or very warm infusions of some 
aromatic herb, as chamomile. 

T prefer the addition of milk of assafcetida, 1 prepared as 
already described above, 3 ii-iii to the whole quantity of 
water. It has always acted exceedingly well for me. Besides 
the rapid emptying of the bowels, an abundant discharge of 
flatus, which is frequently the cause of the pain, is provoked 
by the assafcetida, and the spasm is allayed. 

Injections of cold water are decidedly objectionable and 
aggravate both the pain and the spasm. 

External applications, as hot poultices, hot-water bags, and 
such like, I consider of but little value in the condition under 
consideration. 

Electricity. — The galvanic current may be of great 
value here, more particularly in that form of enterospasm 
which is dissociated altogether from pain. 

II. The spasmodic contraction overcome, and the func- 
tion of the bowel re-established, we will turn our attention 
to the etiological factors and endeavor to banish them. 

If a catarrhal condition of the large bowel exist, as 
shown by the evidence derived from the fasces, and 
catarrh is a not infrequent cause of spasm, we will seek 
to cure the same. 

If a neurasthenia be responsible for the condition, we 
will treat the same upon the lines already indicated, 
resorting at first only to the gentlest measures of the 
various methods of mechanical treatment. 

Occasionally, the enterospasm may be due to the exag- 
gerated use of sharp condiments, as pepper, — especially 
the red, — ginger, etc., or combinations of these in the 

1 The milk has seemed to me to act much better than the tincture. 



TREATMENT OF SPASTIC CONSTIPATION 329 

form of the various sauces. A return to a plain diet will 
be the first requisite for a permanent cure. 

Spasmodic Stricture of the Rectum. — All lesions being 
excluded, the line of treatment just advocated for entero- 
spasm is well adapted to the treatment of spasmodic 
stricture of the rectum. I believe, however, that here 
assafcetida will do more good than any other of the 
group of antispasmodics ; for the reason that these cases, 
with rare exceptions, are found in persons with hysterical 
tendencies, or, at least, with an inclination to disturbance 
of the nervous equilibrium. 

The wonderful success of Stromeyer 1 with this remedy 
should certainly encourage us to give it a thorough and 
conscientious trial in those rather mysterious troubles of 
the rectum where nothing can be found locally to account 
for the great suffering. I can myself bear witness to the 
remarkable effects of very large doses of this drug. 

The assafcetida should be administered in massive doses, 
ten to fifteen grains, four times a day. With it we can 
give some tonic according to the indications that the 
patient presents. 

From its well-known beneficial action in spasmodic 
affections elsewhere, 2 the application of the galvanic cur- 
rent seems certainly indicated. The mode of application 
might be in this wise : A medium-sized electrode, cathode 
over the region of the solar plexus, and another and some- 
what smaller electrode, anode over the sigmoid flexure at 
its lowest reachable point. Duration of application, about 
three minutes. The cathode is then placed over the 

1 Erfahrungen iiber Local-neuroseu, Hannover, 1873. 

2 Erb, Elektrotherapie, loc. cit. 



330 CONSTIPATION IN ADULTS 

caecum and the anode about a hand's breadth in ad- 
vance upward ; the two poles are thus carried gradually 
over the whole large bowel down to the farthest point, 
possible, of the sigmoid flexure ; or the cathode may 
remain stabile and the anode alone be labile. Then the 
cathode is replaced over the caecum, the anode retained 
at the S. flexure, and the continuous current allowed to 
flow through. Duration, four minutes. The internal 
method (unipolar or bipolar) may be tried. 

Spasm of the sphincter without local lesion (spasmodic 
constriction of the anus). 

Spasm of the sphincter without local lesion is chiefly 
an affection of hysterical or neurasthenic persons, and in 
its treatment this must be taken into consideration. 

For the hysterical, large doses of assafoetida will be 
prescribed, and for the neurasthenics, those remedies that 
give tone and vigor to the system according to the indica- 
tions presented, as given more in detail in the next chapter. 

For the local manifestation, the topical application of 
belladonna, in the form of ointment, to the sphincter, with 
suppositories of belladonna or of atropia for the rectum, or 
belladonna administered internally, is here also in place. 

Hyosciamus and cannabis indica may take the place of 
belladonna ; but they are, as a rule, not as effective. 

They may be given in combination with belladonna. 

A cathartic will sometimes act very nicely and break 
up the spasm. 1 When these measures fail to bring relief, 
we will have recourse to a mechanical measure which is 
always effectual, namely, forcible dilatation. 2 

1 Kelsey, loc. cit. 

2 " De la Dilatation Forcee dans le Traitement de la Constipation Opi- 



TREATMENT OF SPASTIC CONSTIPATION 331 

Forcible dilatation may be made with the hands alone, 
or with the aid of instruments. When made with the 
hands, the modus operandi is this : " Both thumbs are 
introduced into the rectum [first one, then the other], 
back to back, well beyond the sphincter ; then, taking 
a purchase from the buttocks with the outspread ringers, 
carry the thumbs gently and slowly, but forcibly, apart 
until their palmar surfaces are arrested by the ischial 
tuberosity." x 

When the sphincter muscle has become large and hard 
from this unnatural exercise, — the strong and long-con- 
tinued contractions, — we will, after having stretched it 
in one direction, turn the thumbs and stretch the sphincter 
in the other direction. We will then, with some press- 
ure, massage the sphincter all around, making petrissage 
between the thumb and forefinger, and again pull the 
anus apart with four fingers, two on each side. Under 
this treatment the sphincter will give way completely, and 
feel like a well-beaten steak, or like putty. 2 If it be pre- 
ferred to do this instrumentally, one of the various anal 
specula, where the separation and holding apart is accom- 
plished by means of screw power, may be used therefor. 
Van Buren, as do most of the modern rectal surgeons, 
preferred the manual method. 

As the procedure is a very painful one, it is best done 
with the patient under the influence of an anaesthetic 
(ether, chloroform). This is more particularly so in weak 
and nervous patients (usually women), or when the pro- 

niatre," Championnere, L., Journal de Medecine et de Chirurgie Pratique, 1877. 
Gazette Medicate d, Hopitaux, 1877. 

1 Van Buren, loc. cit. 

2 Allingham, Diseases of the Rectum. 



332 CONSTIPATION IN ADULTS 

cedure is necessarily a more prolonged one, as when the 
sphincter muscle is unduly thickened. 

In strong and vigorous persons, when dilatation alone 
is necessary, anaesthesia may be dispensed with. 

Where no general anaesthetic is administered, a local 
anaesthesia by means of cocaine, ten to fifteen per cent 
solution, should be produced. 

The patient is placed in the knee-elbow position, and the 
buttocks being well drawn apart, he is asked to press down ; 
the anus and sphincter being thus unrolled, they are painted 
thoroughly with the solution and repainted ; then a little wad 
of cotton-wool, moist with the solution, is placed in the ring of 
the sphincter, and the anus permitted to retract and the but- 
tocks to fall together. After a few minutes the wad is removed 
and replaced by a fresh one. In about ten minutes a decided 
anaesthesia of the parts is effected. 

If the spasm be due to reflex irritation from the urethra 
or the meek of the bladder (and this is a point that should 
always be inquired into in spasmodic troubles of the anus 
and rectum), we will have to attend to these before we 
can expect permanent relief. In the meanwhile we will 
be able to allay the spasm with the suppositories of atro- 
pia or belladonna (alone, or combined with morphia ac- 
cording to formulae above given). I have in this way 
succeeded in affording rapid relief from spasm of the 
sphincter ani coming on in the course of a severe 
gonorrhoea. 



CHAPTER XXV 

TREATMENT OF CONSTIPATION DUE TO IRRITABLE 

RECTUM 

Under the terms of Irritable Rectum, Hysterical Rec- 
tum, Nervous Rectum, has been described a derangement 
of the lowermost segment of the large bowel, character- 
ized seemingly by a hyper-irritability of the rectal mucous 
membrane, or of sections thereof (the hyper-irritability is 
frequently confined within * circumscribed patches), or of 
the nervous filaments distributed thereto, and an absence 
of all apparent local lesion that might account therefor. 

We must exclude from this category those cases in 
which well-defined disease of the urinary tract is found, 
as this may, as has already been stated with regard to 
spasm of the sphincter, produce other disturbed conditions 
of the rectum. 

That the nervous system is mainly at fault, is demon- 
strated by the fact that the trouble is met with only in 
persons with a well-marked tendency to hysteria or already 
hysterical, and in persons in whom the nervous equilib- 
rium has been disturbed by exhaustion of the nervous and 
general systems. 

This derangement presents itself to us with diverse 
phenomena. Sometimes it is a sense of uneasiness in the 
rectum, a sort of nagging feeling, as it were, that makes 
the person afflicted aware that he has such an organ and 

333 



334 CONSTIPATION IN ADULTS 

keeps his mind constantly npon it, until he can think of 
nothing else and becomes morose and melancholy. At 
other times it is a marked pain on defecation, so great as 
to almost fill the patient with terror at the thought of an 
evacuation, and cause him to go as long as possible with- 
out one. Or the pain may come on at regular or irregu- 
lar intervals, even with a marked periodicity of almost 
malarial correctness. At other times it is characterized 
by a general collapse, that comes on with the stool, though 
there may be no pain at the time ; nothing but an inde- 
scribable sickening sensation, as one patient expressed 
himself. A cold sweat breaks out upon the person af- 
fected, the hands become cold, the pulse feeble, there is 
a sense of nausea and a feeling as if one's last hour had 
tolled. 

In the treatment of this most annoying, and to the 
patient sometimes terrible, derangement much tact will 
be required and careful study of the individual case. 

In the hysterical, large doses of assafcetida are cer- 
tainly indicated, and promise success. What this large 
dose is has been already stated. If, for any reason, assa- 
fcetida cannot be taken, the valerianate of zinc in pill, 1 
or in the form of elixir (to which also an addition of the 
tincture of valerian can be made), will prove of decided 
benefit. 

In cases of nervous exhaustion (neurasthenia), of gen- 
eral debility, it will be our first care to build up our 
patient, to invigorate him. Abstention from mental 

1 B Zinc. Valerian. grs. ii 

Extract. Valerian. grs. ii 

Extract. Gentian. q. s 

M. ft. Mass. et ft. pillul. I. Sig. One pill three times a day. 



work ; abstention from the usual pursuits, if possible ; 
moderate exercise in the open air ; diversion of the mind 
(Zerstreuung), — will be advised. The diet will be care- 
fully regulated, and such tonic medication as may appear 
indicated, prescribed. 

Iron (for the anaemic), in the form of Blaud's pill (one 
pill three times a day, and increased every fourth day by 
one, until three pills are taken three times daily *), or as 
the syrup of the iodide of iron and manganese. A good 
preparation of a similar character is Gude's pepto-man- 
ganate of iron (pepto-mangan). We can also give the 
iron in the form of a valerianate. 

Arsenic. 

Phosphoric acid, with bark (especially good in cases of 
nervous prostration). 

The hypophosphites with strychnine. If the digestion 
is impaired, we will be greatly aided in our restorative 
efforts by the administration of hydrochloric acid with 
some bitter infusion, as of gentian or cascarilla, or with 
nux vomica or strychnine. 

Several of these remedies may be combined in one pre- 
scription. Goodell 2 prescribed a pill as follows (Pillul. 
Sumbul. Comp.) : 

$ Extract. Sumbuli gr. i 
Assafoetida. grs. ii 

Ferri Sulphat. gr. i 

Acid. Arsenios. gr. -fa 

M. make one pill. Sig. One pill three times daily. 

The quantity of assafoetida is rather too small to be of 
much benefit. 

1 Goodell, loc. cit. 2 Loc. cit. 



336 CONSTIPATION IN ADULTS 

Or we may prescribe a pill like this : 

$ Zinc. Valerianate grs. ii 

Ferri Valerianat. gr. i 

Strychnina. Sulphat. gr. ^ 
Extr. Cannab. Indie. gr. 1 
Extr. Gentian. q. s 

M. make one pill. (If preferred, the mass can be put into a 
capsule.) Sig. One pill three times a day. 

^ Zinc. Valerianat. 
Ferri Valerianat. 
Quinia. Valerianat. aa gr. i 
M. ft. Mass. et ft. pillul. No. I. Sig. One pill three or 
four times daily. 

Goodell also prescribed the following : 

I£ Aur. Chlorat. Natron. gr. J 

Auri et Sodii Chloridum 
Chloride of Gold and Soda 
Zinc. Valerian. grs. ii 

Extract. Hyosciam. gr. i 

M. ft. Mass. et ft. pillul. No. I. Sig. One pill three times 
a day. 

In addition, we may resort to the various hydropathic 
procedures already indicated above. I have seen very 
good results in building up a broken-down nervous system, 
from a properly arranged hot-air bath of very short dura- 
tion, followed by the cold rain-bath or the Scotch douche 
to the vertebral column and body generally. 

For the sudden paroxysms of pain, nothing is so effec- 
tive, according to Goodell, as antipyrin in doses of five to 
ten grains, or hyoscin, grain y^-g, administered every two 
hours until the suffering is relieved. A Spanish-fly plaster 



CONSTIPATION DUE TO IRRITABLE RECTUM 



337 



of the size of a quarter or half dollar, applied over the 
coccyx, has done me good service. 

Local applications of ointments or anodyne injections 
are of no benefit ; rather harmful 
than aught else. 

Of the greatest benefit, how- 
ever, both in a curative sense 
and for the relief of the imme- 
diate suffering (better even than 
the remedies above named for this 
last purpose) is the local applica- 
tion of cold. It may be applied 
by means of the Atzperger appa- 
ratus. 

This apparatus consists of a short 
metal cylinder to which are attached 
an affluent and an effluent pipe. To 
the cylinder is fixed a hollow, pear- 
shaped, metal stem, without any 
openings, which, well oiled, is carried 
into the rectum. The arrangement 
of the apparatus is as shown in the 

cut. The water flows in from an elevated vessel, and flows 
out through the effluent pipe into a vessel on the floor. 1 

By the constant inflow of cold water and the outflow of the 
warmed water, the parts are kept refrigerated. 

Or it may be accomplished by means of Winternitz's 
device. 

This consists of a hollow metal staff, six to twelve centimetres 
in length, ending in an olive point which, as well as the taper- 
ing neck, is provided with numerous small orifices. This staff. 




Atzperger Apparatus. 



1 Winternitz, loc. cit. 



338 



CONSTIPATION IN ADULTS 




at its lower extremity, divides into two branches like the double- 
current catheter. To one of these branches is attached an 
affluent pipe, carrying water from a vessel placed at an eleva- 
tion, and to the other branch, an 
effluent pipe, which carries off the 
warmed water to a vessel on the 
floor. Just above the point of 
union of the two branches, a metal 
disc with a grooved border is fixed. 
The staff is covered with a rub- 
ber bag (ice-bag) or a thin fish 
bladder, and its open end attached 
firmly to the grooved border of 
the disc. The bladder or bag is 
wound snugly around the staff, 
well oiled and introduced into the 
rectum. The water being allowed 
to flow in through the affluent 
tube, whilst the effluent one is 
shut off (by means of clasp or 
cord), the bladder is filled and becomes distended. This dis- 
tention can be carried to any required extent, and we may thus 
have compression with refrigeration. 1 

If the sensitiveness of the parts be too great to tolerate 
the apparatus (which is not often the case), we can first 
anaesthetize them in a measure by the application of a 
ten to fifteen per cent solution of cocaine, by means of 
the applicator or by the aid of small wads of cotton intro- 
duced gently into the rectum. Or we can resort to the 
application of carbonic acid (C0 2 ), which the investigations 
of Brown-Sequard have shown to have a marked anaes- 
thetic effect upon the tissues. 2 

1 Winternitz, loc. cit. 

2 Comptes Rendus des Seances et Memoirs de la Societe de Biologie, 1882. 
Pr ogre's Medical, 1882. 



WlNTERNITZ's DEVICE. 



CONSTIPATION DUE TO IRRITABLE RECTUM 



339 



We can do this readily with the contrivance devised for 
this purpose by Dr, A. Rose of this city. He describes it 
as follows: 

" It consists of a bottle holding a pint or more with a wide 
mouth and a rubber stopper, the latter perforated so as to admit 
a glass tube which, at the external 
end, is connected with a rubber tube 
to which is attached a nozzle to be in- 
troduced into the rectum." 

The bottle is filled with water about 
one-third full, not quite up to the in- 
ner extremity of the glass tube. Into 
the water six drachms of bicarbonate 
of sodium are put, and when every- 
thing is ready for the application, 
one-half ounce of tartaric acid, in 
large crystals, is added, and the vessel 
quickly closed. 1 

The cooling apparatus can be 
left in the rectum for an hour or 
two, and the application can be 
repeated on the same or on the following day. 

The injection of cold water into the rectum sometimes 
suffices. Mathews 2 relates a rather remarkable case of 
this character which, after innumerable measures and 
things had been tried in vain, was promptly cured by an 
injection of cold water. 3 

1 New York Medical Journal, March 9, 1895, " Therapeutic Effects of 
Carbonic Acid." 

2 Mathews, loc. cit. 

3 See on irritable rectum, Goodell, Mathews, Kelsey, loc. cit. 




CHAPTER XXVI 

TREATMENT OF CONSTIPATION DEPENDENT UPON GENITO- 
URINARY TROUBLES 

This form of constipation has already been alluded to 
elsewhere. It remains only to be said that chronic affec- 
tions of the genito-urinary tract, and more particularly in 
the male, may be the exciting cause of a chronic form of 
constipation. 1 They do this, sometimes, by provoking a 
spasm of the sphincter ani, as has already been said; at 
other times an irritable condition of the rectum is devel- 
oped, and then again, as in spermatorrhoea, we cannot 
account for it except on the grounds that the nerve fila- 
ments of the lower segment of the rectum and the nerve 
centre in the lumbar section of the cord are obtunded, or that 
the irritability of the whole nervous system is lowered. 

As will suggest itself at once, the etiological factor 
must be promptly attended to, to permanently cure the 
constipation. Here, also, the Atzperger cooling apparatus 
or the device of Winternitz will be of great service. 
Winternitz 2 regards it as highly efficacious in spermator- 
rhoea, as well as in cases where a chronic inflammatory 
condition persists. Its value in cases of seminal weakness 
has but lately received additional confirmation. 3 

1 Peyer, loc. cit. 

2 Winternitz, loc. cit. 

3 New York Medical Record, April 13, " A New Treatment of Seminal 
Weakness," etc., by Alfred Wiener. 

340 



CONSTIPATION FROM GENITO-URINARY DISEASES 341 

The introduction of the cold sound will be resorted to 
where indicated. We may, in place of the sound, have 
recourse to the psychrophor, a cooling apparatus for the 
urethra. 




PSYCHBOPHOB. 



It needs no long explanation. It is a closed double-current 
catheter, dividing, as that instrument does, at its lower extremity 
into branches. To one of these is connected an affluent, and to 
the other an effluent pipe. The arrangements for the inflow of 
water are the same as for the other cooling devices already 
described. It is introduced into the urethra, and allowed to 
remain for the length of time that may seem proper. 

In cases of chronic inflammation it will be introduced 
so that the point passes just beyond this locality. In cases 
of spermatorrhoea the point should pass the pars prostatica 
of the urethra, reaching up to the sphincter of the bladder. 

The instrument should be used methodically, but not 
too frequently. The temperature of the water should not 
be too low; from 57° F. to 54° F. generally suffices. It 
should not be lower than 50° F. 

Duration of application, about eight minutes ; at most, 
twelve minutes. 1 

I have obtained excellent results in cases of sperma- 

1 Winternitz, loc. cit. 



342 CONSTIPATION IN ADULTS 

torrhoea with the use of the cold pack, from the umbilicus 
to the knees, as described in Chapter XVIII. I direct 
that the patient be put into the cold pack every morning 
for two hours. 

At night, before retiring, a warm bath is taken to relax 
the tonus of the small ring muscles about the vesiculae 
seminales. 1 

Where the psychrophor is used, the other cooling devices 
mentioned above are, of course, dispensed with. 

In the meanwhile, the bowels will be kept soluble by 
means of cold-water injections, of mild and tonic laxatives, 
as the tonic laxative of the formulary, or by means of 
laxative mineral waters, as Hunyadi Janos, Pullna, Carls- 
bad, Saratoga. 

If, after the ailments of the genito-urinary tract have 
been cured, there remains a weakness, a torpidity of the 
bowels, we will treat this in the manner already set forth 
for atonic constipation. 

1 Illoway, " Hydrotherapeutics," Cincinnati Lancet and Observer, 1877, 
and other papers on the Summer Diarrhoea of Children. 



CHAPTER XXVII 

FISSURE OF THE ANUS 

Fissure of the anus may be the cause of the spasm of the 
sphincter ani or even of the rectum. The treatment therefor 
will be found in detail in the various works on the " Diseases 
of the Rectum." As to forcible dilatation, which with many 
is a favorite mode of treatment, this has been already described 
in full. 

Fissure of the anus may, as has been said, result from con- 
stipation. It occurs in those cases where the fseces become 
very much inspissated and indurated and aggregated together 
into large masses which then require much force and much 
violent dilatation of the sphincter for their expulsion. Under 
these conditions it will be found that despite the best and most 
thorough treatment there will be a tendency to a return of the 
fissure. To obtain a permanent cure, it will be necessary to 
treat the atony of the intestine with the various mechanical 
measures. 

We will employ massage ; this will break up the large lumps 
and will stimulate the secretion of mucus, and thus effect a 
better lubrication. We will avail ourselves of the benefits to be 
derived from the clyster, and direct the use, daily, before going 
to the closet, of a small injection, one half to one pint, of cold 
water to still further soften the faecal masses. 

These injections can be continued for a time (two or three 
weeks) even after the fissure is entirely healed. 

In this way abrasions of the delicate mucous membrane 
lining the sphincter ani will be inhibited. I have succeeded 
in healing, in this wise, fissures that have recurred again and 
again, without resort to any operative procedure or local treat- 

343 



344 CONSTIPATION IN ADULTS 

ment other than the light application of the solid stick of 
argentum nitricum. 

The further precautions to be taken, are these : 
In all cases of fissure or abrasion the use of paper as a cleans- 
ing material after defecation is strictly and absolutely prohibited. 
Cotton-wool, absorbent cotton, is prescribed for this purpose. 
As long as the fissure is open, the parts are to be cleansed with 
a mild solution of boracic acid (two tablespoonfuls of the satu- 
rated solution to a glass of water). After it is healed, I direct 
that there be applied to the sphincter (after it has been cleansed 
with a wad of dry cotton) the following solution : 

I£ Acid. Tannic. 3 i 
Glycerin. 5 ii 

M. ft. Mixt. Sig. Use as directed. 

The patient presses down again (unrolls the sphincter) and 
applies the above solution on a wad of cotton, holding it against 
the sphincter for a few minutes. 

This is continued for two or three weeks, and is for the pur- 
pose of hardening the parts and at the same time closing up 
and healing at once any abrasion or fissure that may have been 
then produced. 

The prohibition against the use of paper, even toilet paper, 
must be carefully observed for a long time, at least six months. 



CHAPTER XXVIII 

HEMORRHOIDS 

It is not the scope of this work to go into the details 
of the surgical treatment of piles, of their treatment by 
the injection method (injection of carbolic acid or of 
admixtures thereof into the body of the tumor), or of 
their treatment with acids. These can be found in the 
excellent works of Kelsey, Mathews, Bodenhammer, Ball, 
and Van Buren. This chapter here is only intended to 
direct attention to certain other measures, not so well 
known to the profession in 'general, that are available for 
the treatment of haemorrhoids, when the more radical 
methods are refused or cannot be resorted to for one rea- 
son or other. That these measures, primarily intended to 
relieve the constipation, the congestion, are not infre- 
quently very effective in causing the dispersion of the 
tumors has been shown by much observation, and has 
been verified to me in my own clinical experience. A 
number of ladies in my clientele were invariably, after 
every confinement, troubled with haemorrhoids which 
caused both constipation and suffering. By prompt 
treatment after the method described here, without re- 
course to any forcible measures, the haemorrhoids dis- 
appeared not to return again till after the next labor. 
In two cases, where pregnancy did not recur, there was 
no recurrence of the piles. These measures are : 

345 



346 CONSTIPATION IN ADULTS 

A proper regulation of the diet. 

Exercise. 

Massage. 

Hydropathic treatment. 

I. A Projjerly Regulated Diet. — What has been said 
above, under this head, with reference to the treatment 
of atonic constipation, applies here as well. All things 
that tend to promote the activity of the intestines, to 
invigorate their various structures, must contribute to the 
cure of haemorrhoids. Only this need be set forth more 
particularly that the use of spices, as black pepper, ginger, 
cinnamon, must be very much restricted; that highly sea- 
soned foods and condiments are to be altogether avoided, 
and that alcoholic liquors, especially red wines and bran- 
dies, must be absolutely prohibited as directly and posi- 
tively injurious. 

II. Exercise. — All that has been said before holds good 
here. The supposition that horseback riding is productive 
of piles is fallacious. 1 

III. Massage. 

[a) Abdominal massage as already described. 

The introductory emeurage is an important part of the 
treatment, and is made, as already stated, from the 
periphery to the centre, i.e. from the symphysis of 
the pubis to the navel. 

Beating of the sacrum is especially indicated and, 
according to Reibmayer, of much efficacy. 2 

If not inflamed, the hemorrhoidal tumors themselves 

1 In addition to the authorities quoted, see " Equitation and Cycling," etc., 
by Bodenhammer, New York Medical Journal, November 2, 1895. 

2 Loc. cit. 



HEMORRHOIDS 347 

can be massaged (effleurage and light petrissage). To 
subject inflamed tumors to such treatment is not alone 
barbarous, but very dangerous. 1 

Massage of the haemorrhoids is made within the rectum. 
The patient is placed on his side, or in the lithotomy position, 
and the tip of the finger, well oiled, first introduced, and then 
gradually and slowly the whole finger pushed up as far as 
required. 

For the effleurage, light strokes, as long as possible, are made. 
For petrissage, the tumor is slightly compressed between the 
tip of the finger and the rectal wall. 2 

(b) Gymnastics. 

Active Exercise, Figs. 8, 9, 10. 

Resistance Exercise, Figs. 13, 14, 15, 18 a and b, 19. 

Passive Exercise, Figs. 21, 23, 24. 

IV. Hydrotherapy. 

(a) The injection of cold water into the rectum and 
bowels, both for its evacuating as well as its tonic effects 
upon the muscles of the rectum and the walls of the ves- 
sels. Van Buren 3 believed that a better way is to obtain 
these two different effects separately, by two distinct 
procedures ; namely first inject a large quantity of water, 
not cold, — even tepid, if there be much accumulation and 
induration of faeces, — to soften the faecal matter and 
effect its discharge ; then follow with a small, cold injec- 
tion, " about a tumblerful, and as cold as can be comfort- 
ably borne," for its constringing action and tonifying 
effect upon the tissues of the part involved. This last 
is allowed to become absorbed. 

I prefer the ordinary cold injection as already described 

1 Reibmayer, loc. cit. 2 Reibmayer, Die Unterleibs-Massage. 3 Loc. cit. 



348 CONSTIPATION IN ADULTS 

here ; I think the effect of even lukewarm water is preju- 
dicial. 

The injection can be given once daily, — best in the 
morning before rising, or at bedtime before retiring, — or 
once every other day, according as the stool keeps soft or 
not. 

This is a very effective measure. 

(b) The cold douche to the lower part of the trunk, 
both anteriorly and posteriorly. The Scotch douche is of 
great benefit, and can be applied to the perineum also. 

(c) The hemorrhoidal bandage : This is a sort of T 
bandage. It consists of two parts : a circular part to be 
applied as a girdle around the abdomen, and a vertical 
portion, attached to the middle of the girdle and at right 
angles to it, posteriorly, which is applied along the back 
downward, drawn through between the thighs, over the 
perineum, up over the abdomen, to the centre of the girdle 
in front. This vertical section consists of two separate 
leaves of muslin. 

Its mode of application is this : The inner leaf of the 
vertical section is placed in cold water, allowed to remain 
therein for some time, and then wrung out thoroughly. 
The bandage having been put on (and the vertical section 
attached to the girdle by buttons), the wet leaf is pressed 
down upon the vertebral column and upon either side of 
it, passed through between the thighs upon the perineum, 
and up over the abdomen to the girdle in front, where it 
is affixed. The outer, or dry leaf, which, if impermeability 
be desired, can have oiled silk or gutta-percha paper sewed 
on to it, is laid over the wet leaf, and covers it completely. 1 

1 Winternitz, loc. cit. 



HAEMORRHOIDS 349 

(d) Atzperger's or Winternitz's cooling device for the 
rectum may be used. With the latter we can get, if we 
so desire, besides the tonic action of the cold, a compres- 
sion effect upon the tumors, which is also of some 
advantage. 1 




The Hemorrhoidal Bandage. 

The dietary regulations, and those as to exercise, are 
always appropriate in persons with hemorrhoidal tenden- 
cies, no matter what plan of treatment be followed. 

The massage treatment may be employed alone, or in 
combination with hydropathic procedures. 

Of the hydropathic procedures described, one or more 

1 Winternitz, loc. cit. 



350 CONSTIPATION IN ADULTS 

may be employed, alone, or in combination with massage. 
The cold injection, as especially efficacious, should always 
constitute a feature of the plan of treatment. 

The combination of massage and hydrotherapy makes 
the treatment more effective, and gives quicker results. 

As regards the administration of medicines, it may be said 
that, if the mechanical treatment above described can be carried 
out fully and faithfully, medication is unnecessary ; otherwise, 
we may avail ourselves of certain well-known remedies that 
tend to tone up and invigorate all the structures of the bowels, 
and to stimulate their functional activity, to fortify the good 
results obtained with other procedures. These remedies, which 
have already been referred to more in detail in the chapters 
devoted to atonic constipation, are : strychnine, physostigma, 
and ergot. These may be given alone or in combination. 
Nux vomica or strychnine should be given in very small and 
more frequently repeated doses. It has been my experience 
that, in this way, a better effect is obtained. Ergot or ergotin 
can be administered more freely. Belladonna, which, in small 
doses, is said to stimulate peristalsis, 1 may be prescribed with 
one or the other of the remedies named. The formula above, 
given for a combination of physostigma (strychnine or nux 
vomica can take its place, if preferred), ergot, and belladonna, 
may serve very well here. 

We may have recourse at times, with advantage to the 
patient, to some of the remedies belonging to the group of 
hepatic stimulants. Hydrastis 2 has been highly commended 
as a very efficient remedy. It is used both internally and 
locally. Internally it is given in doses of five to ten drops of 
the tincture of Hydrastis Canadensis in a wineglassful of water 
three or four times daily. Locally an infusion or decoction of 
the bark is injected into the rectum ; the tincture can be used 
for the same purpose, 3 ss-i being mixed with one or two ounces 

1 Brunton, T. L., Textbook of Pharmacology, Therapeutics, etc., 1888. 

2 Phillips, Materia Medica and Therapeutics. 



HEMORRHOIDS 351 

of cold water, and injected into the rectum before rising in the 
morning or on retiring at night. 1 In conditions of torpid liver 
or of marked biliousness 2 we may give with our strychnine or 
ergot, small alterative, if the term may be allowed, doses of 
rhubarb, euonymin, juglandin, or of stillingia. 

Purgatives should, of course, be avoided. If, however, cir- 
cumstances compel us to resort to them in order to keep the 
bowels soluble, the mild saline laxatives, as magnesia sulphate, 
cream of tartar, Rochelle salts, etc., are to be preferred. These 
may be combined with sulphur, which at one time was supposed 
to have some special influence over this affection, or with rhu- 
barb or with jalap or with senna, as in the Pulveris Grlycerrhizoe 
Co., as may seem most appropriate. 

3 Potass. Bitartrat. 5 in 

Sulphur Flor. 5 i 

Mix thoroughly. Sig. Take two tablespoonfuls of the 
powder and mix in a cup or glass with sufficient molasses to 
make a thin batter. Of this take one to two teaspoonfuls every 
morning and evening, sufficient to keep the bowels easily and 
painlessly moved. 

# Magnesia. Sulphur. (F. Barker) 3 
Magnesia. Carbonic. 
Potass. Super Tart. 
Sulphur Sublimat. aa 3ss 
Mix thoroughly. Sig. From a teaspoonful to a tablespoon- 
ful in a glass of sugar water every morning. 

4 



^ Pulv. Jalap. 


(Ellis) 


Potass. Bitartrat. 




Potass. Nitrat. 


aa 3ss 


Confectio Senna. 


§i 


Syr. Simpl. 


q. s 


M. ft. Electuarium. Sig. A bolus of the i 


three times a day. 





1 Ringer, Therapeutics. 2 Brunton, T. L., Disorders of Digestion, etc. 

3 Lectures on the Puerpural Diseases. 

4 J. C. Wilson, Complete Medical Formulary. 



352 CONSTIPATION IN ADULTS 

t> Soda. Sulphat. (Rosenheim) 1 

Pulv. Rhei Radio. 

Sulphur, depurat. aa 10. (= 3iiss) 

M. ft. pulv. Sig. About one-fourth teaspoonful (Messer- 
spitzvolV) at a dose. 

In debilitated or ansemic persons, an aloetic pill with or 
without iron will sometimes be better borne than the salines. 



$ Pulv. Aloe Socotrin. 


(F. Barker) 2 


Sapon. Castil. 


aa 3 i 


Extract. Hyosciam. 


3ss 


Pulv. Ipecac. 


grs. v 


M. ft. pillul. (argent.) No. XX. 


Sig. One pill morning 


and evening. 




In anaemic cases a scruple of sulphate of iron is ordered in the 


above formula. 





Various local applications have been recommended. 
These may be in the form of fluids to be injected into 
the rectum (as the fluid extract of ergot diluted with two 
parts water, ergot 3ii, aqua 3iv), in the form of sup- 
positories or of ointments which are applied to the tumors 
directly. 3 

Dr. J. B. James reports the successful treatment of 
haemorrhoids solely by the application of calomel with 
the finger to the tumors. 4 

The local applications are more particularly indicated 
when the tumors are extruded and inflamed and painful. 

1 Loc. cit. . 3 See " Formulary." 

2 Loc. cit. 4 British Medical Journal, February 20, 1892. 



CHAPTER XXIX 

OIL INJECTIONS 

An application or method of treatment, already re- 
ferred to in the chapter on " Spastic Constipation," highly 
recommended by Kussmaul and Fleiner, and already 
favorably mentioned by older writers, is the injection of 
oil into the rectum, — the oil clyster. 

In all ailments of the intestinal tract not accompanied 
by motor disturbances, oil injections are indicated. More 
precisely, its therapeutic indications may be summarized 
thus: 

I. Wherever, from functional disturbance or organic 
change, the evacuation of faeces is inhibited, so that stag- 
nation and accumulation thereof occurs. 

II. In all forms of mechanical obstruction to the dis- 
charge of faeces, by compression of the bowel by abnor- 
mally enlarged abdominal organs, as liver, spleen, uterus, 
ovaries, or prostatic gland ; by constriction of the gut by 
pseudo-membranous peritoneal exudation ; by stenosis 
from cicatrices or neoplasms; by sudden bending of a 
section of the large intestine. 

III. In all cases of intestinal irritation ; in subjective 
troubles of diverse forms, colicky pains, circumscribed 
inflammatory processes ; in proctitis, colitis, typhlitis ; 
in ulceration, tubercular or dysenteric, — the oil clyster 

353 



354 CONSTIPATION IN ADULTS 

is indicated, and even though evidences of involvement 
of the peritoneum present themselves. 

Excepted are all irritative conditions of the intestine 
accompanied by increased peristalsis, whereby contenta of 
the small intestines, considerable quantities of unchanged 
bile and natural pancreatic juice, are thrown rapidly into 
the colon. In these cases an injection of oil would be 
followed by a saponification of the same as it came in 
contact with the bile and pancreatic juice, and the setting 
free of oleic acid and the formation of glycerines. These, 
having a stimulating action upon the intestine, would ag- 
gravate the irritation already existing. 

The oil clyster is said to be of exceptional utility in the 
bowel complaints that accompany ailments of the stomach ; 
also in anaemic individuals and such whose nutrition is 
much impaired. 

Technic of the Oil Clyster. — The very best of olive 
oil, — the virgin oil, if it can be obtained, — or the purest 
of cotton-seed oil, only should be used. The other oils, 
occasionally employed, as poppy-seed oil or rape-seed oil, 
are not extant in this country. 

To avoid thermic or mechanical irritation of the mucous 
membrane of the large bowel, whereby peristalsis might 
be at once excited, the oil should be warmed before it is 
injected into the bowel. 

Oil is warmed by placing the bottle or vessel containing it 
into a vessel of hot water. 

The ordinary fountain syringe (whether the reservoir 
be a rubber bag or a tin or glass can) answers very well. 
The rectal point should have a calibre sufficiently large to 



OIL INJECTIONS 355 

be commensurate with the slow outflow of the oil. Its 
borders should be smooth and well rounded. The follow- 
ing figure indicates what, according to Fleiner, its shape 
should be. 




^^^^ 



(Can be made of hard rubber, bone, or glass.) 

The patient is placed in the horizontal position on a bed 
or couch, on the dorsum or on the side. The pelvis is ele- 
vated (20 to 25 cm. = 8 to 10 inches), especially if it be de- 
sired to reach further portions of the colon, by placing a 
firm (non-compressible) pillow, or a blanket properly folded, 
beneath it. In this, as in the knee-elbow position, a nega- 
tive pressure is developed in the pelvic organs which exer- 
cises an aspirating action upon the fluids thrown into the 
rectum. Over the pillow or blanket a rubber sheet or 
oil-cloth is placed, so as to avoid soiling by the oil. 

The reservoir of the syringe is elevated above the 
rectum to a height of about 50 cm. ( == about 20 inches) 
or more and the oil allowed to flow in. 

After taking the injection, the patient should remain 
lying down for at least one hour. 

In cases of constipation with accumulation and indura- 
tion of faeces, where the injection should reach up into 
the colon as far as possible, 400 to 500 c. cm. of oil are 
required for the injection for adults; for children, 50 to 
150 c. cm., according to the age. In conditions other 
than constipation, in affections of the colon descendens, 



356 CONSTIPATION IN ADULTS 

of the sigmoid flexure, or of the rectum, 100 to 150 c. cm. 
(can be injected with a hard rubber syringe) ; for children, 
30 to 50 c. cm. will suffice. 

The outflow of the oil is, as readily understood, rather 
slow. It takes from fifteen to twenty minutes for 400 
c. cm. to flow out completely. 

The evacuation does not at once follow the injection. 
Usually several hours elapse before an evacuation occurs. 
If the gut be very much filled with hardened fseces, it 
may be necessary, if the required effect is not produced by 
the oil in three or four hours, to follow it with an injection 
of warm water. 

A single application will not suffice, according to Fleiner, 
to have the oil reach the caecum, even by changes of posi- 
tion on the part of the patient. A daily repetition of the 
clyster is therefore necessary, if any benefit is to be de- 
rived from this method of treatment. When the maxi- 
mum effect has been obtained, it can be recognized by the 
character of the stool, which will now resemble very much 
the contents of the small intestines, and sometimes even 
give biliary color-reactions. Sometimes the maximum 
effect is obtained in two, at other times it will be three, 
or even more, days. 

After the maximum effect has once been obtained, the 
clysters are given at intervals of two or three days, or 
even longer, according to the indications in the case. 
The quantity of oil is also diminished to 250. to 200 c. cm. 

The oil discharged from the bowels shows, very fre- 
quently, marked changes : the most striking is the change 
in color, which may run all the shades from dark yellow 
to olive green. Besides the fsecal odor, it sometimes 



OIL INJECTIONS 357 

acquires a sour smell, and a chemical examination shows 
an increase of acidity. 1 

If abnormal fermentative or putrefactive processes are 
to be combated, one or two per cent of salicylic acid may 
be added to the oil. 2 

The oil acts both mechanically and chemically, By its 
mechanical action, which sets in already in the lowest 
segment of the gut, it loosens and detaches the scybala 
from the intestinal parietes, penetrates the indurated 
faecal masses and softens them, and indirectly, through 
the softened faeces, excites peristalsis. 

Its chemical action is this : When it is brought in con- 
tact with unchanged bile and normal pancreatic juice, a 
process of saponification is set up, in the course of which 
oleic acid is set free and glycerine is formed, and both of 
these products have an irritating effect on the intestinal 
parietes, and thereby excite peristalsis. 

Summarized, the effects of the oil are : 

It detaches the scybala from the intestinal wall. 

It softens the indurated faeces. 

It has an emollient, soothing effect upon irritated 
tissues. 3 

It stimulates peristalsis. 

It inhibits the resorption of water (from the faeces) by 
the mucous membrane. 

Usually the oil clyster does not cause any disturbance 
at all ; occasionally, only, the patient experiences an un- 
pleasant sensation, as if something were crawling in him 

1 Fleiner, Berliner kiln. Wochenber., 1893. 

2 Rosenheim, loc. cit. 

3 T. Lauder Brunton, Pharmacology, etc. 



358 CONSTIPATION IN ADULTS 

(searching out the bowels, some patients described it), 
that may disturb his sleep. This passes away, however, 
in a very short time. 

It is absolutely necessary to cleanse the syringe thoroughly 
after each injection. The rubber tube is filled with water and 
hung up in \J form ; after a time the water is allowed to flow 
out at both ends. This process is repeated several times. If 
the instrument cannot be perfectly cleansed in this way, a little 
absolute alcohol will quickly remove all the particles of oil 
remaining. 1 

1 Fleiner, loc. cit. 



CHAPTER XXX 

SOME OTHER METHODS OF TREATING CONSTIPATION 
(THAT HAVE BEEN RECOMMENDED) 

I. Stretching of the Sphincter Ani for Constipation (not 
due to local lesion). 

In 1889 Dr. C. Cleveland 1 reported some cases of con- 
stipation treated by forcible dilatation of the sphincter 
ani, and with favorable results. Gant 2 has likewise re- 
ported favorably, though he does not confine himself to 
this procedure alone, but makes use also of massage and 
electricity. It is a question, therefore, how much of his 
success can be attributed to the measure under considera- 
tion. Mathews 8 expresses himself rather cautiously. 

It can be readily understood how forcible dilatation 
may be of benefit in those cases of abnormal contraction 
of the sphincter that are occasionally seen in the hysteri- 
cal and the neurasthenic. 4 That the cases relieved were 
of such a character, seems demonstrated by the fact that 
almost all of the cases reported are females, and all with 
either well-developed hysteria or neurasthenia, or at least 
a much-depressed and irritable nervous system. 

1 New York Medical Record, March 9, 1889. 

2 " Non-Medicinal Method of Treating Constipation," by S. C. Gant, The 
Medical Herald, St. Joseph, Missouri, March, 1893. 

3 Loc. cit. 

4 See " Spasm of the Sphincter," Chapter XX. 

359 



360 CONSTIPATION IN ADULTS 

How it could be of any possible benefit in atonic states 
of the intestine is rather difficult to understand, despite 
attempted explanations. At the utmost the benefit here 
would be but temporary and not commensurate with the 
trouble and the suffering caused, especially when we have 
other methods that are in all cases certain of success, 
without any of these drawbacks. 

The manner of effecting forcible dilatation of the sphincter 
ani has been already described in a preceding chapter. It re- 
mains only to be said here that there is also a more gradual 
process, as suitable in the condition under consideration as the 
more forcible procedure, and much more convenient, both for 
the physician and the patient. 

The gradual dilatation is made by means of soft rubber 
rectal bougies. 1 

II. The Application of Boracic Acid. 2 

Flatau treats habitual constipation with boracic acid 
locally applied. His method of treatment is this : 

Where, in consequence of marked relaxation or of 
chronic proctitis, the rectal mucous membrane protrudes 
more or less through the anal orifice, the nates are sepa- 
rated, the anal parts washed with cold water, well dried, 
and about ten to twenty grains (a Messerspitzvoll = what 
will go upon the tip of a dinner-knife) of finely powdered 
boracic acid is either dusted strongly upon the protruding 
rectal mucous membrane or rubbed into it, with a circular 
movement, with the tips of the fingers. 

If there be no such protrusion of the mucous membrane, 
the powder is insufflated into the rectum. For insuffla- 

1 Gant employs this method. Loc. cit. 

2 Th. S. Flatau Berliner klin. Wochenschrift, 1891. 



OTHER METHODS OF TREATING CONSTIPATION 361 

tion a coarser powder, one still somewhat granular, is 
better and more effective. 

The applications should be made by the physician, ex- 




Whitehead's Instrument 
for Gradual Dilata- 
tion. 



LlJ'I 



mi 



cept in cases of protrusion of the rectal mucous membrane, 
where the patient can be taught to apply the powder 
himself. 

After the application, the patient should remain in the 



362 CONSTIPATION IX ADULTS 

horizontal position for a little time, so as to retain the 
powder in place. 

In from one-half to three hours peristaltic movements, 
which can be noted upon the abdominal parietes, are ex- 
cited in the region of the colon, and abundant watery 
discharges follow. 

In some cases there are in the first days three or four 
stools per day. 

At the outset of the treatment patients must be in- 
structed to obey the slightest indication of a call of nature, 
for if the slight be disregarded the stronger may not 
follow. 

The applications are made at first daily ; then when 
the intestines show more activity, every other day ; then 
twice a week, once a week, twice a month, once a month, 
and then cessation. 

The claim is made that the treatment is not injurious. 

From the exposition of Flatau, it is evident that the 
application of boracic acid acts in the same manner as 
does glycerine, and that it has no special advantage over 
the latter. 

Moreover, it may prove injurious. A case is reported 
where packing of the vagina with boracic acid produced 
pronounced poisoning. That no such effects have been 
as yet noted from the applications to the rectum, may be 
due to the small number of cases in which the treatment 
has been tried. 

It is also very self-evident that a mere irritation of the 
intestinal tract, whether by bougies or by drugs, locally 
applied or internally administered, cannot overcome the 
fundamental difficulty, the atony of the intestines. 



OTHER METHODS OF TREATING CONSTIPATION 363 

III. Treatment by River Gravel {Flusskiesel)} 

Kaczorowsky has had success in treating habitual con- 
stipation with river gravel. 

He directs that the patient take a glass of cold water 
every morning on arising, on a fasting stomach. He 
regards this as the very best and most efficient way of 
softening and thinning the intestinal contents. He also 
directs the use of Graham bread, and gives other dietary 
regulations such as have been already set forth. 

The mechanical measures are the best and simplest, 
and are not followed by any unpleasant side-effects. 
From this standpoint he has made use, besides, of the 
cold-water injections, of river gravel (Flusskiesel) or, 
rather, river sand washed off with hot water. 

' Of this, a teaspoonful to a tablespoonful is taken twice 
daily. It is taken plain without any other menstruum or 
envelope, and washed down with cold water, drunk after 
it. It is much more effective if the grains of sand are of 
the size of flax seeds. 

From an aesthetic point of view the gravel could be 
replaced with coarsely ground marble dust ; the antacid 
properties of this might be an additional advantage. 

From his rather large experience, Kaczorowsky believes 
its use indicated in all cases of habitual constipation. 

He has had remarkable success with it in the treat- 
ment of spastic obstipation in young, nervous persons 
with hyper-excitation of the genital spheres. 

He finds it also indicated in the constipation dependent 

1 Kaczorowsky, Asrodkach wyprizniajacychjelito, wseczegole o Zwirze- 
Przeglad lekarsi, No. 15-17, Krakow, 1886. " On the Intestine Evacuating 
Remedies, more especially as to River Gravel," Virchow u. Ilirsch, Jahresbe- 

richt, 1886. 



364 CONSTIPATION IN ADULTS 

upon chronic heart and lung affections, with consequent 
ansemia and debility. 

Also in the chronic catarrh of any section of the 
intestinal tract. 

IV. Treatment by Suggestion. 

According to Dr. A. Forel, constipation can be readily 
and quickly cured by the " Suggestion " method of treat- 
ment (hypnotization and suggestion). 1 

1 Die Heilung der Stuhlverstopfung durch Suggestion, etc., von Prof. Dr. 
A. Forel, Director der Irrenanstalt Bureholzli, Zurich, Berlin, 1894. 



CHAPTER XXXI 

TREATMENT OF CONSTIPATION IN OLD PEOPLE 

Constipation is one of the more frequent troubles of 
old age. Very often it is only an aggravation of a cos- 
tive condition of the intestinal tract that has long pre- 
viously existed, and even where this is not the case it is 
readily accounted for by the various changes that char- 
acterize this period of human existence. 

An atony of the whole muscular system with a ten- 
dency to atrophy. 

A slowing of all the physiological functions. 

A diminution of the various secretions. 

Moreover, as a result of these changes, less exercise is 
taken, and there is therefore diminished oxygenation ; less 
food is taken, and what is taken is of a more concentrated 
character, and there is therefore diminished detritus. 

Under these conditions nothing can usually be done 
toward a restoration to the normal, but very much can 
be accomplished to make the patient comfortable. 

I. First and foremost we will see to the diet. Though 
we cannot advise much coarse food, we have, nevertheless, 
several articles that are of great utility, and still compati- 
ble with the requirements of old age. These are : 

A glass of cold water, the first thing on rising in the 
morning. 

365 



366 CONSTIPATION IN ADULTS 

Oatmeal with milk and sugar (milk sugar 1 if it can be 
had) ; but preferably, if the patient can eat it that way, 
with (cane) syrup and milk for breakfast. 

Molasses (cane-syrup) or fruit jellies, eaten with bread. 

Fruit puddings (see formulary). 

Baked apples, stewed fruits, comjjots, morning and 
evening. 

II. Exercise. — It is important even for the old to take 
some exercise, both for the reason that it prevents the 
muscular system from relapsing into a state of lethargy 
by thus constantly arousing it, as, also, because it effects 
increased oxygenation of the blood and this more vigorous 
assimilation and greater excitation of muscle. I believe 
it can be maintained as an undeniable fact, that the 
characteristics of old age, in so far as loss of vigor is 
concerned, are less marked in those who continue to 
work, to keep up a state of activity, than in those 
who, naturally indolent, fall into a state of almost abso- 
lute inertia. 

The exercise should be taken, as already indicated, in 
the open air ; a good walk, keeping well this side of the 
limits of fatigue ; horseback riding, carriage riding, in the 
park or open country, — all commensurate with the re- 
maining degree of vigor. 

III. As regards the treatment, more properly speaking, 
it may be said that, as a rule, the more forcible measures 
of the mechanical method will do no good ; massage is of 
no benefit, and of hydrotherapy, only the clyster (hot or 

1 Boas believes that sugar of milk has some laxative properties. Routh 
(on " Infant Feeding "), however, holds that it tends to allay intestinal irri- 
tation, and to check diarrhoea. 



TREATMENT OF CONSTIPATION IN OLD PEOPLE 367 

cold) and the cold bath (with persons accustomed thereto) 
are available and also advantageous. 

Here the well-regulated administration of drugs will be 
of service. The milder of the purgative medicines only 
should be resorted to. Moreover, when a certain article 
of this group has ceased to be effective in a proper dose, 
we should not keep on with it, increasing the quantity 
administered, until it is inordinately large, or until the 
system ceases to react to the agent altogether, but rather 
change it, — take up another remedy and lay this one 
aside. By doing this, we prevent a greater exhaustion of 
the intestinal tract and aggravation of the constipation, 
and also reserve a remedy ; for it will regain its power 
at a later period, when the system will cease to respond 
to this one as it did to the other. 

A well-regulated dinner-pill, for which there are a 
number of formulae all more or less alike, taken an hour 
or two after the midday meal, or just before retiring at 
night, will be all that will be required with many persons. 
When this ceases to be effective, or at the outset, if we so 
prefer, we may prescribe cascara sagrada (as cordial, elixir, 
or pill) or the confection of senna (dose 3 i-ii, once a day), 
or some other lenitive electuarium. 1 A good pill, that 
acts both kindly and efficiently, is composed as follows : 

P> Extract. Jugland. grs. ii 

Extract. Rhei gr. i 

Extract. Nuc. Vomic. gr. ^ 

Extract. Hyosciam. (Engl.) gr. i 

M. ft. Mass. et ft. pillul. I. Sig. One pill at bedtime. 2 

1 See " Formulary." 

2 For other formulae, see "Formulary." 



368 CONSTIPATION IN ADULTS 

If no distress is caused thereby, a purgative need not 
be taken but every other day, or even twice a week only. 

In cases of marked sluggishness of the intestinal tract, 
it may become necessary, after a longer or shorter period 
of time, to effect a more thorough clearing out of the 
bowels. We can accomplish this by means of the decoc- 
tion of rhubarb, the Inf usum Laxativum Viennensis, 1 the 
liquor magnesias citratis, a laxative mineral water, or with 
any of the more active formulae known to physicians. 

This must be borne in mind as a rule governing the use 
of purgatives in the aged, that no agent or formula that 
will gripe must be prescribed ; old people stand such suffer- 
ing very badly. 

It should be our aim in all cases to maintain the intes- 
tinal function by means of the dietary regulations and the 
use of injections, reserving our medicines for those periods 
when the measures named will cease to be effective, and 
for those occasions when a more thorough emptying may 
be required. In many cases we will succeed so well that 
the bowels will act almost normally. When, however, for 
one reason or another this cannot be done, or when such 
treatment is not effective, then we will direct the regu- 
lar administration of medicines in the manner already 
indicated. 

1 Same as Mixtura Sennae Co. The addition of Syr. Rhei Aromat., in the 
proportion of one to three or four of the Mixture, will correct any tendency 
to gripe that it may have. 



CHAPTER XXXII 

FORMULARY 

An evacuation, though not always a satisfactory one, 
may be obtained by means of an injection of glycerine. 
One-half to one ounce of glycerine is injected into the 
rectum with a hard rubber syringe. Or the glycerine can 
be introduced into the rectum by means of a suppository. 

It is applicable more especially in those graver cases of 
acute intestinal disease where an evacuation of the 
rectum, at least, and a discharge of flatus would be 
desirable, but where the use of even mild laxatives is 
contraindicated as fraught with possible danger. 

Mild and useful laxative preparations and formula. 

Elixir or Cordial of Cascara Sagrada. 



I£ Extract. Fluid. Cascara. Sagrad. 3 vi 
Tinct. Nuc. Vomic. 3 ii 

M. Sig. x-xv drops three or four times daily. 



I> Extr. Cascar. Sagrad. fluid. 1 3 i 

Tinct. Nuc. Vomic. gtt. x 

Tinct. Belladonna. m v 

Aq. 3i 

M. ft. haustus Sig. (this dose) to be taken twice a day. 

1 James D. Staples, Hospital Gazette. New York Medical Record, 1892. 

309 



3T0 CONSTIPATION IN ADULTS 

Tonic laxative (formulary East Side Dispensary). 

^ Extr. Fl. Cascar. Sag. 25. = 3 vi J 

Tinct. Cinchona. 15. = 5ss 

Tinct. Nuc. Vomic. 5. = 3IJ 

Aq. et Glycerine q. s. ad 60. = q. s. ad 3ii 

M. Sig. Dose one to two teaspoonfuls, repeated every three 

or four hours. 



Pulv. Jalapae Co. very useful in hemorrhoidal conditions. 
Infusum (aut decoctum = frequently prepared as such) 
Rhei. 

U. S. Pharm. 3 ii to the O ss ; dose, half to one wineglass- 
ful. British Pharm. 1:40; dose, one to two ounces. Germ. 
Pharm. 1 : 12 ; dose, one to two tablespoonfuls. 

Very useful in various hepatic ailments. Alkalies or 
acids, as may appear indicated, can be added thereto. 

Tinct. Rhei : dose, one to two ounces. 

Tinct. Rhei et Gentian. 

Pulv. Rhei Co. 3 i to 3 i every three or four hours. A 
very excellent formula for all those conditions wherein 
a laxative would be very useful, and where yet the great- 
est care must be exercised not to excite but the very 
mildest of peristalsis. 

Infusum Laxativum Viennensis. (Mixtura Sennce Co., 
senna, manna, Rochelle salts, etc.), a very pleasant, and, 
at the same time, effective purge. Its action can be regu- 
lated by an increase or diminution of the dose. For a 
mild effect give one to two tablespoonfuls every hour or 
two ; for a more energetic action, one-half wineglassful 
every two hours. 

Pulv. Glycerrhizae Co. (Pulv. Liqueritice Co.), grs. xv-xx 



FORMULARY 



371 



every two or three hours. Useful in catarrhal conditions 
of the respiratory tract. 

Pills 



I£ Resin. Podophyllin 
Extr. Colocynth. Co. 
Extr. Hyosciam. 
Ole. Tiglii 
Ole. Menth. Pip. 
M. ft. pillul. No. XII. Sig. D 
at bedtime). 


grs. vi 
grs. xii 
grs. xii 
gtt. i 
gtt. i 
ose one pill (usually taken 


fy Extr. Colocynth. Co. gr. i ss 
Pulv. Rhei gr. i 
Extr. Alcoh. Nuc. Vomic. gr. i 
Podophyll. Res. ♦ gr. 1 
Extr. Belladonna. (Engl.) gr. i 
Extr. Hyosciam. gr. 1 
M. ft. Mass. et ft. pillul. No. I. Sig. One pill at bedtime ; 
repeated in the morning if necessary. 


^ Extr. Colocynth. Co 
Extr. Hyosciam. 
Pulv. Aloes Socot. 
Extr. Nuc. Vomic. 
Podophyllin, p. 
Ipecachuan., p. aa 
M. ft. pillul. (argent.) No. XII. 
at one dose. 


3i (Fordyce Barker) 1 
grs. xv 
grs. xv 
grs. v 

gr. i 
Sig. Two pills to be taken 


^ Podophyllin grs. hi 
Extr. Colocynth. Co. 
Sapon. Castiliens. aa grs. iii 
Extr. Alcoh. Nuc. Vomic. grs. v 
Extr. Hyosciam. grs. vi 
M. ft. Mass. et divid. in pillul. No. XII. Sig. One pill 
every morning. 

1 Loc. cit. 



372 CONSTIPATION IN ADULTS 

Formula for protracted use, as in the constipation of the 
old: 

Confectio Sennge. Dose, 3 i-ii (not to be prescribed when 
dyspepsia complicates the constipation). 

Electuarium Lenitivum Wintheri. — Manna, 2 ; syrupus 
limonis, 10 ; pulpa tamarindorum, cassia praeparata, aa 2 ; 
folia sennas, cremor tartari, aa 1^. Dose : one teaspoonful. 

Electuarium Mannse. — Manna, saccharum, aqua foeni- 
culi, aa 2 ; pulvis rad. iridis, | ; oleum amygdalarum 
dulcium, 1. Dose : a heaping teaspoonful. 1 

A more energetic preparation of this character, and 
adapted to cases of extraordinary lethargy of the intestine, 
is the confectio scammonii of the German or British 
pharmacopeia. 

These formulas, though old-fashioned and rather forgotten, 
are, nevertheless, very useful for the persons and purpose that 
they have been here recommended for. 



Pillulse Aloes et Assafcetidse (U. S. P., dinner pill). 
Pillulse Aloes et Mastiches (U. S. P. =Lady Webster dinner 

pm). 



3 Podophyllin 0.3 = grs. ivss (Nothnagel) 2 

Extract. Aloes 

Extract. Rhei aa 3.0 = grs. xxxxvi ss 
Extract. Taraxac. q. s. 
M. ft. pillulse No. XL. Sig. One pill at bedtime. 

1 Strumpf, Allgemeine Pharmakopoe. 

2 Wiener mediz. Presse, loc. cit. 



3 



FORMULARY 


Pulv. Rhei 


3iv (Dr. B. Lee) 1 


Pulv. Aloes 


^iii 


Pulv. Myrrh. 


Sii 


Sapo. Hispanien. 


% ii ss 


Olei Cajeput. 


3i 



373 



M. The powders are to be rubbed together, and the soap 
then worked in, afterward the oil. The well-mixed mass is 
kept in a tight-stoppered bottle. The fresher the powder, the 
better it is. Three grains make an effective dose which does 
not irritate. 



t) Extract. Jugland. 


grs. ii 


Resin. Podophyllin 


g r - To 


Pulv. Rhei Rad. 


gr. i 


Extr. Hyosciam. (En 


glish) gr. i 


M. ft. Mass. et ft. pillul. No. I. 


Sig. One pill at bedtime. 


t> Podophyllin 


gr. yL (Brundage) 2 


Extract. Belladonn. 


g r - To 


Extract. Nuc. Vomic. 


g r - i 


Extract. Hyosciam. 


gr- i 


Pulv. Capsic. 


gr- i 


M. ft. pillul. No. I. Sig. Take at bedtime. Dose : one 


to two pills. 





It is directed that the pill be taken nightly for a week, then 
every other night, until natural evacuations follow. 

For Constipation with Flatulence 

1$ Extract. Colocynth. Co. 
Terebinth. Veneta. 
Pulv. Aloes Socot. 
Extract. Nuc. Vomic. 
Extract. Hyosciam. (English) 
M. ft. Mass. et ft. pillul. No. I. Sig. One pill two to three 
times a day. 

1 New York Medical Record, 1894. 

2 Lilly, Handbook of Pharmacy and Therapeutics. 



gr. 


3 


gr. 


1 


gr. 


1 ss 


gr- 


i 


gr. 


1 



374 CONSTIPATION IN ADULTS 

^ Extract. Senna, fluid. (F. Barker) 1 

Syrup. Zingibr. aa 3 vi 

Tinct. Jalap. % ss 

Tinct. Nue. Vomic. gtt. 40 

M. Sig. A tablespoonful in a wineglassful of water and 
sugar. 

For Constipation with Haemorrhoids 

Pulvis Antihsemorrhoidalis. 2 



# Pulv. Rad. Rhei 

Potass. Bitartaric. Depur. 
Flores Sulphur. 


3 parts 




Magnes. Carbonic. 
Senna. Folior. 




aa 3 parts 




Semen. Fcenicul. 




aa 2 parts 




M. bene et adde 








Eleosacchar. Fcenicul 




16 parts 




M. ft. pulv. Sig. Dose 3 i 
fore breakfast, or at bedtime). 


(can 


be taken in the 

3iss (Ellis) 3 
5ii 


morning 


^ Sulphuris loti 

Confection. Senna. 






Potass. Nitrat. 




3i 




Syrup. Aurantii Cortic. 
M. ft. Confectio. Sig. One to tw 


q. s. 
drachms twice 

(Ellis) 3 


a day. 


5, Pulv. Jalap. 

Potass. Bitartar. 






Potass. Nitrat. 


aa 


3 ss 




Confection. Senna. 


3i 






Syrup. Simplic. q. s. 
M. ft. Electuarium. Sig. A bolus of the size of 


a hazel- 



nut, three times a day. 



1 Loc. cit. 

2 Strumpf, Allgemeine Pharmakopoe. 

3 Wilson, Complete Medical Pocket Formulary. 



FORMULARY 375 

Ointments 

For all Forms of Rectal Pain l 

I£ Succus Conii S ii boiled down to 3 i ss 
Lanoline q. s. ad 5 i 

M. ft. Ungt. Sig. Apply locally. 

For Haemorrhoids 



^ Cerat. Simpl. 


3 vi 


Vaselin. 


3 iii 


Pic. Liquid. 


3 i ss 


Extr. Belladonna. 


3 i ss 


Acid. Gallic, sive Tannic. 


3 i 


M. ft. Ungt. 





$ Ungt. Gallge Co. 3 i (F. Barker) 2 

Extr. Opii Aquos. * 3 i 

Solut. Ferri persulphat. 3 i 
M. ft. Ungt. Sig. Apply to the tumors. 



^ Tinct. Hamamel. 


3 xii 


Lanolin. 


3 vi 


Petrolat. ad 


5 xvi 


M. ft. Ungt. 





fy Extract of Garlic 1 part 3 
Olive Oil 2 parts 

M. to be applied to the tumors, or, if they be concealed, a 
drachm of the mixture is injected into the rectum. 



5 Pulv. Opii 3ii (Ellis) 4 

Unguent. Pic. Liquid 3i 
M. ft. Unguent. 

1 Medical Standard, Chicago, 188S. 2 Loc. cit. 

8 H. Kinnard, Pacific Medical and Surgical Journal. New York- Medical 
Record, 1887. 

4 Wilson, Complete Medical Pocket Formulary. 



376 CONSTIPATION IN ADULTS 

P> Hydrarg. Chlorid. Mit. (Calomel) 3 ii (Bartlett) 1 
Unguent. Petrolei (Vaselin.) %i 

M. ft. Unguent. 

Suppositories (for concealed haemorrhoids) 

$ Acid. Gallic. 

Extract. Ergot. aa gr. i 

Extract. Belladonn. (English) gr. 1 

Extract. Hyosciam. (English) gr. i 

Ole. Theobrom. 3 i 

M. ft. Suppositor. No. I. Sig. Introduce one into the 
rectum night and morning. 

(Pancoast) 

Use one morning and 



fy Acid. Tannic. 0.06 = gr. i (Rosenheim) 3 

Chrysarobin. 0.1 = gr. iss 

Extract. Belladonn. (seu Opii) 0.02 = gr. 1 
Ole. Theobrom. 2.0 = 3 ss 

M. ft. Suppositor. No. I. Sig. Introduce one once or twice 
a day. 

Ointment (for external piles) 

r> Chrysarobin. grs. xvi (Kossobudski) 4 

Iodoform. grs. vi 

Extract. Belladonn. grs. xii 

Vaselin. 3 vi 

M. Sig. A small quantity to be applied to the tumor sev- 
eral times a day, the parts having been previously washed with 
a solution of carbolic acid 1 to 50, or of creolin 1 to 100. 

1 Wilson, Complete Medical Pocket Formulary. 

2 Complete Medical Pocket Formulary. 

3 Loc. cit. 

4 Complete Medical Pocket Formulary. 



5, Extract. Kramer. 




3 ii 


(P- 


Pulv 


. Opii 




grs. v 




Ole. 


Theobrom. 




3 ss 




M. ft. 


Suppositor. 


No 


. X. 


Sig. 


night. 











FORMULARY 377 

Wash for Bleeding Piles 

5- Alum. pulv. 3 ii 

Acid. Tannic. 3 ss 

Aqu. Destill. S,v 

M. Sig. One-half to be injected at a time, and to be re- 
tained as long as possible. 



fy Acid. Nitric. f § ss — i (Ringer) 1 

Aqu. Destill. f § viii 
M. ft. Lotio. Sig. Apply as a wash. 



Schmey reports that he has had great success in the treat- 
ment of haemorrhoids (protruding) with the daily applications, by 
means of a camel's-hair pencil, of a two per cent (2%) solution 
of silver nitrate. The applications are altogether painless. 2 

Formulae for Injection -7 Method of Treatment (of piles, 

extruding) 
^ Glycerin. 3 ii ss (Meniere's) 3 

Acid. Phenic. (Carbolic.) gtt. xx 
Morphia. Sulphat. grs. v 

M. Sig. Inject five to ten drops into the tumor. 



~fy Acid. Salicylic. 3i 

Glycerin. 3 iss 

M. rub the two well together, and add 

Acid. Carbolic. 3 ii 
M. 

then rub together Borac. 3 i 

Glycerin. 3 iss 

Now mix the two mixtures thoroughly together, and allow 
to stand until clear. 

Sig. For small tumors three to five drops, for large tumors 
five to eight drops, to be injected. 4 

1 Complete Medical Pocket Formulary. 

2 Allgemeine medic. Centralzeitung, 1895, No. 73. Therapeut. Monat- 
shefte, October, 1895. 8 jy €W York Medical Record, 1886. 

4 A Shuford, New York Medical Record, 18S7. 



378 CONSTIPATION IN ADULTS 

Dietetic Preparations 

Apples. 

Baked Plain. — Procure some highly flavored apples 
(others, except as to aroma and taste, will answer as 
well), — hard winter apples are to be preferred, — take 
the core out at the centre by boring, and fill the cavity 
thus created with sugar. Put into a dry pan, and place 
in a good hot oven. Ordinarily the apples will be thor- 
oughly baked in about sixteen to twenty minutes. To 
make certain that they are well done, they can be tested 
by thrusting a fork into them. 

Baked Plain. — Take apples as above, cut them in 
halves, remove the core, etc., refit them together, and tie 
them somewhat loosely in pieces of very thin paper previ- 
ously smeared with good fresh butter; then place them 
in the oven at a moderate, steady heat for twenty-five 
minutes. Remove the paper; grate some fine loaf-sugar 
over them, set aside to cool, and serve when cold. 1 

Baked with Syrup. — Take of the finest loaf-sugar half a 
pound, and of soft, filtered water eight tablespoonfuls ; 
boil down together at a gentle heat in a small stew-pan 
for a quarter of an hour. Then pare three good, well- 
flavored apples (others will answer), removing the core by 
boring (as with a slicing blade), place them in a shallow 
tin pan, pour over them the syrup just prepared, add a 
wineglassful more of water, and acidulate with ten drops 
of lemon-juice. Place in the oven at a moderate, steady 
heat for thirty minutes. Remove into a dish, set aside to 
cool, and serve when cold. 2 

1 Morgan, Indigestion, Constipation and Haemorrhoids, London. 2 Ibid. 



FORMULARY 379 

Stewed. — Pare and quarter three or four or more fine 
apples, — having first prepared a syrup as above directed, 
— add a teaspoonful of lemon-juice and three very thin 
strips of lemon-peel ; put all these ingredients into a 
shallow stew-pan, and place over a very gentle fire, so 
that a barely simmering heat is maintained ; after they 
have stewed thus for fifteen minutes, pierce the apples with 
a fork from time to time to ascertain when soonest they 
become thoroughly softened ; as soon as this is the case, 
pour them off with the syrup ; set them aside to cool, and 
serve when quite cold. 1 Or, pare the apples, cut them in 
quarters, and put into a stew-pan with enough water to 
reach half the height of the apples ; close the stew-pan 
tightly, and let them steam until they have been well 
done (ordinarily one-half to three-fourths of an hour). 
They are then taken off, allowed to cool somewhat, re- 
duced to a pulp, and seasoned with sugar and lemon-peel 
(the lemon-peel can be omitted if desired) to suit the taste ; 
then put in the oven again for three to five minutes to allow 
the seasoning to become thoroughly incorporated therein. 
Pour off into a cold dish, and serve when quite cold. 

If preferred, the seasoning can be put in at the outset. 

Stewed with Raisins, Prunes, or Figs. — Prepare the 
apples as above, and add to them about one-fifth the 
quantity of raisins cut into halves, or one-eighth the quan- 
tity of prunes opened and stoned, or one-eighth the quan- 
tity of figs sliced up into smaller pieces. After the 
completion of the boiling, when the apples are well done, 
mash the fruits together to a pulpy mass, and season with 
sugar and lemon-peel as above directed. 

1 Morgan, loc. cit. 



380 CONSTIPATION IN ADULTS 

Marmalade (can be eaten as soon as cold, or preserved 
in jars for a length of time). — Take eight moderate sized 
and well-flavored apples, — such as will boil down to a 
smooth pulp are required, — pare and remove the core, 
place in a basin, and squeeze over them the juice of a 
lemon. Then prepare a syrup by boiling clown a pound 
of the finest loaf-sugar with a tumblerful of water for 
twenty minutes. When this is done, add the apples and 
lemon-juice — if cane syrup or molasses is used, pour this 
over the apples — and keep at a barely simmering heat 
until the apples are all reduced to a pulp. When this 
object is obtained, submit the stew-pan to a greater heat ; 
add a little grated lemon-peel, stir briskly and incessantly 
until it becomes thoroughly consistent, when it may be 
stored in jars, and set aside to cool. 1 

For the constipated [cane] syrup or molasses is much 
to be preferred in the preparation of the various dishes 
described. 

Grated Apple-Pudding (a most delicious dish). — Grate 
six large tart apples — of good flavor if they can be had — 
into a large bowl ; add half a cup of sugar, raisins, a few 
pounded almonds, the yolks of three eggs, and the whites 
thereof, after having been beaten into snow. A pinch 
of salt must be added. Mix all these together, put into a 
pudding-dish, and bake in a hot oven for thirty minutes. 
It can be eaten warm or cold. For the constipated it is 
best served cold. 

Prune Butter. — Besides in the common way as a stewed 
dish, prunes can be prepared as a butter or a paste which 
can be eaten with bread or with various farinaceous dishes, 

1 Morgan, loc. cit. 



FORMULARY 381 

as grits, macaroni, vermicelli, grated noodles, etc., for 
which it may serve as a top-dressing. It is prepared thus : 
Take one cup of stoned prunes and one cup of water ; boil 
in a stew-pan until soft, mash into a smooth pulp, and 
add the grated rind of half a lemon. 

Fruit Beverages. — A good substitute for alcoholic 
liquors when sweet cider cannot be had. 

Apple Tea. — This drink, which is very pleasant, is best 
made with fruit previously roasted or cooked dry by open 
exposure to the heat of the fire, as on the edge of the hob 
or bars. Four fine apples should be used for every quart 
of tea required, and the best granulated sugar — about 
two ounces — should be added. 

The whole of these ingredients — to which a table- 
spoonful of lemon syrup may be added or not, according 
to the taste — should then be placed in a cylindrical por- 
celain jar sunk in a basin of boiling water, — and boiling 
water should be quickly poured upon the fruit and stirred 
briskly for a few seconds, — covered, and set aside to 
cool ; strained through four folds of muslin, and served 
as desired. 

Apple Drink. — Another kind of drink may be made by 
slicing six full-sized apples into a basin, stoning a quarter 
of a pound of raisins, and bruising down two ounces of 
loaf-sugar ; the whole of these ingredients should be 
thrown together into three pints of boiling water, and 
kept boiling for thirty minutes. After this the whole 
should be set aside in a capacious covered jar to cool, and 
should be strained through a fine hair sieve, and served 
when cold. 1 

1 Morgan, loc. cit. 



382 CONSTIPATION IN ADULTS 

Lemon Tea. —r- Take a large, juicy lemon, cut it in two, 
and remove the seeds ; put it into a pot with two ounces 
of water and two to four pieces of loaf-sugar (the sweeten- 
ing to be regulated by the taste), and boil down to a cup 
and a half. Can be taken warm as a tea or cold as a 
drink. 

Grated Noodles. — Make a stiff noodle dough and grate 
the same on a coarse grater, dipping in flour occasionally 
so that it may grate more easily. Put in the oven to dry, 
being careful not to allow them to brown. Rub to crumbs. 
Have ready boiling salt water in which to throw the 
crumbs. Boil thirty minutes, then strain off. Melted 
butter may be poured over if desired, or any fruit — butter, 
marmalade, or jelly can be used as a top-dressing. 



PART II 

CONSTIPATION IN INFANTS AND 
CHILDREN 



■ 




Frontisplate I. 

Arrangement of small intestines in situ in infant twelve days old. 

384 




Frontisplate II. 

Infant, twelve days old. Small intestines removed. 1, Stomach 2. Transverse 

Colon. 3, Sigmoid Flexure. 4, Csecum and Appendix Vermiformis. 

385 



H 



■ 



CHAPTER I 

CONGENITAL CONSTIPATION 

Constipation, as is well known, is one of those ail- 
ments that is common to all classes of society, from the 
palace to the hovel, and that is met with at all periods of 
life, from the infant " mewling and puking in the nurse's 
arms," to "the lean and slippered pantaloon." 

The constipation of infants can be divided into two 
great categories : 

Congenital constipation. 

Acquired constipation. 

Congenital Constipation 

Congenital constipation may manifest itself 

(a) At once, immediately after birth, by a failure of 
discharges from the intestinal canal ; an intestinal obstruc- 
tion, with all the acute symptoms, appearing in a very 
brief period of time. 

(b) Or, as a constipation proper, by a deficiency in the 
frequency and quantity of faecal matter discharged from 
the bowels, with, if the difficulty be not remedied by nat- 
ure or by man, consequent complete obstruction with all 
its phenomena, after a longer period. 

(c) Again, it may manifest itself by occasional par- 
oxysms of obstruction with complete cessation of evacua- 

386 



CONGENITAL CONSTIPATION 387 

tion, whilst in the intervals between these paroxysms the 
alvine discharges may be fairly regular and sufficient in 
quantity. 

It depends upon some malformation, malposition, or 
other abnormality of some portion of the intestinal canal, 
of the small intestines, of the colon, of the rectum, of the 
anus. 

A. Malformations of the Rectum and Anus. — The mal- 
formations of this portion of the gut which are apparently 
the most frequent, or, at least, have been most frequently 
noted, have been thus summed up by Bodenhammer in 
his classical work on this subject. 1 

1. The anus may be more or less preternaturally nar- 
rowed at its margin, and* sometimes for a short distance 
above. 

The contraction is not always limited to the anus, but ex- 
tends occasionally up into the canal itself. This narrowing of 
the rectum is sometimes found to be due to numerous folds 
which project from its inner wall into the lumen of the cavity, 
and obstruct more or less, according to their degree of develop- 
ment, the performance of its physiological function. The anal 
opening and the cavity of the rectum may present all the dif- 
ferent degrees of stricture, from that into which the smallest 
probe cannot be introduced to that which opposes but little 
obstruction to the passage of a small-sized catheter. According 
to the degrees of stricture, we will have either intestinal ob- 
struction or one or the other forms of constipation. 

Sometimes the marginal integument of the anus extends over 
the border of the sphincter muscle, and produces thereby both 
contraction and deformity. 

2. The anus and rectum may be normal, but the simple, 

1 The Congenital Malformations of the Rectum and Anns. 



388 CONSTIPATION IN INFANTS AND CHILDREN 

thin, and delicate membranous septum of foetal life may 
still exist, and thus produce a complete occlusion of the 
anal orifice. The anal aperture is sometimes completely 
closed by a thick and hard membrane, or a substance 
analogous to it. 

3. The anus may be entirely absent, no sign whatever 
indicating where it should be, the scrotal raphe being con- 
tinued without interruption back to the coccyx. In such 
cases the rectum may also be partially or entirely absent, 
and the sphinctores ani may or may not be present. 

4. The rectum, at some point in the pelvis, more or less 
distant above its natural outlet, may terminate in a cul-de- 
sac, and either hang loosely or be attached to some of the 
surrounding parts. The anus may or may not be wanting. 

5. The cavity of the rectum may be interrupted at a 
variable distance above a well-formed anus by a thick or 
thin membranous septum projecting into it like a dia- 
phragm. Sometimes there are two or more of such mem- 
branous septa. These may form complete or incomplete 
partitions (as they are perforated or not, or do or do not 
reach fully to the opposite side) between the various 
sections of the rectum. 

Where there are two complete septa, the part between 
them remains narrow and undistended, like a cord. Where 
the septa are incomplete, the calibre of the part of the 
rectum lying between them may attain the normal size. 

With the exception of these septa the canal is usually 
perfectly natural. 

Case 40. Complete closure of the rectum. Lannelongue 
(Observation I, Microcephalic et Hydrocephalie), (Bulletins 
et Memoires de la Societe de Chirurgie, 1884). 



CONGENITAL CONSTIPATION 389 

January 11th, 1884, there is brought to us to the hospital 
a new-born child, five days old. . . . The father of the child 
is twenty-two years of age, small and rather puny in appear- 
ance ; he claims never to have had syphilis ; he is in good 
health ; he has a father and a sister living, both enjoying good 
health ; his father had been rachitic. The mother of the child 
is eighteen years old, and is rather sickly ; had typhoid fever 
at the age of twelve. One of her sisters, it was said, had 
inverted viscera, the heart being to the right. Besides, she 
has two phalanges missing on the right hand. 

The Infant. — He is very vivacious ; he has had no stool 
since his birth. Furthermore, he is microcephalic. . . . 

Examination of the anal region shows that the anus is well 
formed, and that the anal portion of the rectum has a little over 
three (3) centimetres in length ; I could introduce the finger, 
although a little difficulty was experienced ; but, leaving the fin- 
ger in the infundibulum I felt no sort of impulse, despite the 
efforts and the cries of the child. It was justifiable, therefore, 
to conclude therefrom that, in a measure, the terminal portion 
of the rectum was wanting. The distance between the ischii 
was normal. 

An artificial anus was made after the method of Littre. 

An incision is made with the bistoury in the region of the 
left iliac fossa ; the skin and subjacent muscular layers are 
divided, and we come upon the small intestines which come up 
and out through the opening made ; they are pushed back, the 
large bowel is seized, and fixed with numerous sutures to each 
lip of the wound. It is incised; but very little matter escapes. 
A dressing of boracic acid is applied. 



The child grows weaker and weaker, and on January 16, at 
4 a.m., it expired. It had lived ten days. 

January 17 : Post-mortem examination. 

Abdominal cavity opened. 

The peritoneum shows plainly traces of peritonitis ; there 
are bands of false membrane causing adhesions between various 



■I 



390 CONSTIPATION IN INFANTS AND CHILDREN 

loops of intestine, and there is a manifest redness of the intesti- 
nal structure. 

No effusion of faecal matter into the peritoneal cavity. 

The artificial anus had been made in the sigmoid flexure, 
and its borders were adherent to the abdominal integument. 
Immediately below this anus, the flexure pursues its course to 
the level of the sacro-iliac symphysis; here, this part of the 
intestine is dilated, and there succeeds to it rather bruskly a 
round, cylindrical rectum, whose dimensions are not greater 
than those of an ordinary penholder. The rectum follows its 
ordinary course into the concavity of the sacrum without in- 
creasing in size, and, arrived at the coccyx, it continues on with 
the anal section of the gut. The last portion is about three (3) 
centimetres in length, and has a calibre superior to that of the 
other portions of the rectum. Thus the rectum between the 
sigmoid flexure and the anal section presents a contraction so 
great that, if flattened down, its calibre is less than one (1) 
centimetre ; it has the form of a solid cord. 

*********** 

Opening the sigmoid flexure above the rectum down to the 
dilated portion, we are struck by the fact that at the point 
where the rectum so bruskly succeeds to it, the cavity is im- 
permeable. In a word, the sigmoid flexure terminates in a 
cul-de-sac, and from this cul-de-sac, without communicating 
with it, the rectal . cord starts. Likewise below, the anal sec- 
tion of the bowel is separated from the rectum by a complete 
partition, which we could not force during life, even after con- 
siderable manipulation with a stylet and with a female sound. 

After death we vainly injected liquids ; we could not pass 
the inferior partition ; we now broke the valvule with a stylet, 
which then passed readily into the rectum up to the ampulla 
of the sigmoid flexure ; there the stylet pushes forward a thin 
mucous membrane which forms a horizontal and convex plane, 
from the side of the sigmoid flexure, without presenting the 
slightest orifice. For greater precision, we injected fluid into 
the rectum ; it elevated the mucous membrane, but it did not 
penetrate into the sigmoid flexure. There existed, therefore, 



CONGENITAL CONSTIPATION 391 

in this part of the bowel two distinct and perfect diaphragms, 
the one situated between the sigmoid flexure and the rectum, 
and the other between the anal and the pelvic portions of the 
rectum. The lowest diaphragm is located three and a half (3|) 
centimetres from the anus ; the highest is eleven (11) centi- 
metres from the anus, or seven and a half (7 J) centimetres 
from the lower diaphragm. 

Between these two partitions the intestine could not become 
distended by the meconium, for the reason that no meconium 
could pass into it ; and although it looks like a solid cord, it is 
nevertheless a canal lined with mucous membrane. This ex- 
plains also why, during life, the finger placed in the rectum 
felt no shock or impulse ; the meconium did not get there. 

6. The anus being normal, the rectum for a greater or 
lesser distance above it may degenerate into a solid mass 
resembling a cord ; or tjiis degeneration may be confined 
to its superior portion only, the part reassuming its cylin- 
drical shape again as it approaches the anus, forming, as 
it were, a pouch at its inferior extremity. 

7. The rectum may be obliterated throughout its whole 
extent by a thickening of its coats, its walls being approxi- 
mated and firmly adherent, as if they were glued together ; 
or this obliteration may take place at one or two points 
only in the course of the rectum, the canal at these places 
appearing as if tied together with a tape, the anus and 
intervening space being natural. 

8. The rectum may be present in its proper cylindrical 
form, whilst its cavity may be blocked up with a substance 
of cellulo-fibrous character ; an anus may be present or 
may be altogether wanting. 

9. The rectum may terminate in the bladder or in the 
urethra, in the vagina or in the uterus, or in a cloaca in 
the perineum with the urethra and the vagina. In these 



392 



CONSTIPATION IN INFANTS AND CHILDREN 



cases there is generally no sign of an anus ; yet sometimes, 
though rarely, it does exist, and permits the introduction 
of a probe to the extent of four lines. 

10. The rectum may terminate in the sacral region by 
an abnormal anus ; it may be prolonged in the form of a 
fistulous sinus and terminate by an abnormal opening at 
different points in the perineum, at the glans penis, labia 
pudendi, etc. The normal anus is generally absent. 

11. The rectum may be altogether wanting, and its 
place taken by a fatty cellular tissue. In these instances 
the colon ends in a cul-de-sac, with or without a ligamen- 
tous appendage in continuation. No normal anus exists, 
but sometimes an abnormal one does. 



The Congeni- 
tal Malfor- 
mations OF 
the Anus. 



SYNOPTIC TABLE 

Preternatural narrowing. 

Occlusion by a thin membrane. 

Occlusion by a thick, hard mem- . Atresia orificii 

brane. ani. 

Partial or complete absence. 
Abnormal, 
f Occlusion of the j 1. By one membranous septum. 

rectum. j 2. By two or more membranous septa. 

1. By an agglutination of its parietes. 

2. By the puckering of its parietes. 



The Congeni- 
tal Malfor- 
mations OF 
the Rectum. 



Obliteration of 
the rectum. 



P r e t e r l) atural 
termination 
of the rec- 
tum. 



Absence of the 
rectum. 



3. By thickening and induration of 
its parietes. 

1. In a cul-de-sac. 

2. In the bladder. 

3. In the urethra. 

4. In the vagina. 

5. In a cloaca in the perineum with 
the urethra and the vagina. 

6. In the ano-perineal region at differ- 
ent points. 

7. In the sacral region. 
j 1. Partial. 
( 2. Complete. 1 

1 Cases illustrative of these deformities are given in extenso by Boden- 
hammer in the work quoted, and numerous others have since been reported. 



CONGENITAL CONSTIPATION" 393 

B. The Colon may be the seat of the difficulty. This 
may be in the form of a malformation of the colon, of a 
malplacement thereof, or of an obstruction in any part 
thereof. 

1. Malformations, (a) A part of the large boivel may 
be wanting. — The rectum and anus may be wanting, as 
already stated. 1 The colon may be absent in its entirety. 
For illustrative cases, see Bodenhammer, The Congenital 
Malformations of the Rectum and Anus. 

(b) The colon, or any section thereof, may be rudimentary. 

Case 41. Charles Atkin, F.R.C.S. (Lancet, London, 1885, 
1, 203). 

A male infant two days old was brought to the infirmary, 
not having passed any motion since its birth. On examination, 
a small depression was found J at the usual situation of the anus, 
but it would not admit even a small probe. The abdomen was 
distended, hot, redder than normal. . . . Mr. Atkin explored 
the ischio-rectal region, but failed to meet with any bowel, so 
an oblique incision was made above and parallel to Poupart's 
ligament, on the left side ; not finding the colon, a piece of 
small intestine was stitched and opened in the usual manner. 
Meconium and flatus came freely from the wound. The child 
was evidently eased and took some milk. . •. . After a quiet 
night, during which the temperature was never elevated, it be- 
gan to sink, and died during the evening of the following day. 

At the autopsy, the whole colon and rectum were found to 
be rudimentary, being about the diameter of an ordinary quill ; 
at first sight the tube seemed to be a solid cord, and it was not 
till after the removal of the whole alimentary canal that it was 
found that firm meconium could be pressed along with the aid 
of considerable force. The csecum and vermiform appendix 
were differentiated from the main canal, but corresponded in 
degree of development. 

1 In addition to cases quoted by Bodenhammer, see case of Ilurd, Boston 
Medical and Surgical Journal, 1888. 



394 CONSTIPATION IN INFANTS AND CHILDREN 

(c) It may be abnormally contracted. 

Case 42. Arthur H. Dodcl (Lancet, London, 1892, 1, 1299). 

In this case unusual straining at stool was the earliest symp- 
tom which attracted the attention of the nurse, but the infant, 
notwithstanding, thrived noticeably during the first three 
weeks. At first there were one or two actions of the bowel 
each day, but very shortly only every other day. About the 
end of the third week sickness commenced, occurring from five 
to ten minutes after taking the breast, and at that time only, 
which was then thought probably due to too frequent suckling. 
This symptom, however, increased in severity, the amount re- 
jected at first being only slight; but in a few days from its 
commencement, the mother thought the whole meal, or nearly 
so, was returned. I should mention that the character of the 
sickness was peculiar, the vomited matter not only rolling over 
the edges of the mouth, but " shooting out " (if I may use the 
expression) beyond the mother's lap into the room. There was 
evidently a great deal of pain, the child lying curled up, with 
the thighs flexed tightly against the abdomen, the feet crossed, 
and crying at very short intervals night and day. At the 
fifth week there was a cessation of all symptoms for about 
seven days, but the sickness, constipation, and pain returned. 
Throughout, there was never any distention of the abdomen, 
but double inguinal hernia was produced at a later stage, as a 
result of the perpetual crying and straining. At the seventh 
week Dr. E. G. Whittle saw the case with me, and chloroform 
was administered, but nothing was revealed by the examination. 
No localized enlargement, tumor, or anything could be detected, 
and we came to the conclusion that there was some congenital 
deformity existing in the bowel and thought that no operation 
was justifiable. Constipation increased, . . . the child gradually 
sinking from exhaustion at the end of the twelfth week. 

The necropsy . . . revealed congenital contraction of the 
ascending and transverse colon, which was throughout but 
little larger than an ordinary lead pencil. The head of the 
csecum was normal ; the vermiform appendix was about two 
and a half inches in length ; the descending colon, sigmoid 



■M 



CONGENITAL CONSTIPATION 



395 



flexure, and rectum were distended, but normal, with the ex- 
ception of partial contractions, of an annular character, of the 
sigmoid flexure. The small intestine was abnormally nar- 
rowed ; the ileum, for a few inches before its junction with 
the ca3cum, was very much contracted ; the stomach was pecu- 
liar in shape, resembling an hour-glass contraction near the 
cardiac end. All the other organs were normal. 




Congenital Contraction of the Ascending and Transverse Colon. An- 
nular Contraction of the Sigmoid Flexure. 

2. Obstruction. 

Case 43. Gould (Lancet, London, 1882). 

A child aged three days suffered from the usual symptoms 
of intestinal obstruction. The belly was opened above Pou- 
part's ligament on the left side. A coil of distended small 
intestine presented, and as no distended large intestine could 
be found, it was carefully stitched to the edges of the incision 
and opened. A large amount of meconium escaped. . . . The 
child died twenty-one hours afterward. At the autopsy there 
was no evidence of peritonitis. The caecum, the lower four 
inches of the ileum, and the first four inches of the colon were 
filled with a firm whitish plug of inspissated mucus of the con- 



396 CONSTIPATION IN INFANTS AND CHILDREN 

sistence of cheese, which was firmly applied but not adherent 
to the mucous membrane. Beyond this, the colon and rectum 
were empty and contracted to the size of a clay pipe stem. 
Above it the small intestines were distended with meconium 
and gas. It was pointed out that there was no fault in devel- 
opment, but obstruction from a plug. 

Case 44. Congenital occlusion of the colon at the ileo-ccecal 
valve. Weiland (Medical News, January 11, 1896). 

On October 26, 1895, at 2 p.m., Mrs. Wr., primipara, aged 
thirty-four years, of Philadelphia, gave birth at full term to a 
boy of apparently perfect development. Nothing unusual was 
observed in the infant until October 27 at 1 a.m., when the 
child began to vomit a darkish fluid which left only a light- 
colored stain on the clothing. As the child had been given 
some tea of a similar color, it was supposed to be that ; at any 
rate, no pathognomonic odor could be detected. This vomiting 
occurred on that day whenever the child was given some nourish- 
ment. As towards evening the bowels had not moved, in spite 
of a little piece of soap that had been put into the rectum, an 
injection of lukewarm water with a little soap was given, which 
returned immediately and brought small cylindrical masses of 
white mucus about 5 mm. in diameter. This, of course, aroused 
suspicion at once ; but the next morning, conclusive evidence 
of an internal pathological condition was furnished by the 
vomited matter, which now was distinctly faecal in odor, and 
had the appearance of meconium. As the first thought was 
that of intussusception, a soft rubber catheter was introduced 
into the rectum, which could be pushed up about eight inches. 
Then the nates of the child, who was already very weak, were 
raised, and plain lukewarm water was injected with a Davidson 
syringe. As the injection returned at once, the anus was gently 
compressed, and about two ounces of water were again injected. 
This procedure increased the vomiting of fsecal matter very 
much, and so was stopped at once ; but the vomiting continued, 
respiration became embarrassed, and soon the child died, about 
forty-eight hours after birth. The post-mortem examination 
showed the following condition of the intestinal tract : the 



CONGENITAL CONSTIPATION 397 

small intestine showed great vascular injection, and was much 
distended with gas, especially near the ileo-csecal valve. Here 
the diameter of this viscus was about 18 mm., the same as that 
of the caput caecum, with which the small intestine was con- 
tinuous, as the lower fold of the ileo-csecal valve was absent, or 
rather very little developed. The upper part, however, of this 
valve, the ileo-colic fold, was developed too much; for it stretched 
across the whole lumen of the bowel and formed a complete 
septum between the colon on the one side, and the caecum, with 
the vermiform appendix and small intestine, on the other side. 
There was not the slightest chance for a communication between 
these two parts. Below this anomalous diaphragm, the caecum 
and small intestine showed well-developed villi, and the entire 
mucous membrane was stained brown with biliary pigment, and 
showed a small amount of meconium. Above the abnormal 
septum, the large intestine was very much contracted, having 
a diameter of only 5 mm. It had also no ascending part, but 
the transverse colon turned back at once to the posterior aspect 
of the abdominal cavity, and ran transversely as far as the usual 
position of the splenic flexure, where the descending colon com- 
menced. The whole colon and rectum, about ten inches in 
length, contained only soft white mucus, and not the slightest 
trace of meconium. Its surface looked white compared with 
the color of the small intestine, and its walls were thin, having 
apparently been arrested in its development. 

3. Malplacement. 

Case 45. A. Jacobi (American Journal of Obstetrics, 1869). 

Twelve to fourteen hours after birth no meconium. . . . 
On the third day, the left iliac region in front, and a little 
above the anterior superior spine, appeared to fill up and yield 
a somewhat duller percussion sound. . . . Operation made in 
this spot ; it resulted in our finding a pouch of the descending 
colon, filled with a large amount of meconium, which was readily 
discharged through the artificial opening. . . . The patient did 
well for a short period, but died of peritonitis on the fifth day 
after the operation. 



398 CONSTIPATION IN INFANTS AND CHILDREN 

Necropsy. — The part of the colon fastened to the abdominal 
wall was no longer dilated. . . . Besides the consequences of 
peritoneal inflammation, nothing was abnormal in the immedi- 
ate neighborhood. All the parts above the incision, and all the 
other viscera, were not diseased. Below the point of incision 
lay the colon turned three times upon itself ; three flexures 
covering each other in such a manner that the subjacent one 
was always about half an inch longer than the one above it. 
The lowest of the three, crowded down into the pelvis, was 
entirely compressed, contracted, and contained nothing but a 
little hardened mucus; the middle flexure contained the same 
mucus, and a small amount of meconium ; the upper one was 
filled with meconium as far as the contracted lumen of the 
bowel would allow, and its outer left portion was the one which 
had appeared dilated by the meconium crowding down from 
above. The inferior flexure reached beyond the median line, 
stretched upward to nearly the anterior superior spine of the 
right side, and from there the intestine turned back in an acute 
angle into the pelvic cavity, doubled upon itself, and reached 
the median line on the right side of the empty bladder, and 
terminated as the rectum in the normal place. When the bowel 
was removed, it measured, from the point of incision in the left 
hypogastrium to the anus, nearly fourteen inches. The ascend- 
ing colon was of normal length ; the transverse colon was not 
in the normal position, but stretched from the right hypogas- 
trium to the left anterior superior spine, diagonally, in an almost 
straight line, forming an acute angle with the uppermost curva- 
ture we have described, and giving rise to the pouch we found 
dilated before and during the operation. 

C. The malformation leading to the constipation or 
obstruction may be located in the small intestines. 

1. The small intestine may he almost entirely obliterated. 

Case 46. Congenital obliteration of the small intestine. 
John Thompson (Edinburgh Medical Journal, 1892, Vol. 2). 
Infant, two and one-half days old, seen on November 12 



CONGENITAL CONSTIPATION 399 

(1890), on account of complete obstruction and constant vomit- 
ing, along with my friend, Dr. Home Ross. 

*********** 

Present Condition. — The child is well developed, and of 
natural size. The skin is bright red with a strong orange tint. 
The conjunctiva are only slightly yellow. The lips, the vertex 
of the scalp, the palms and soles, and the neighborhood of the 
anus are all markedly cyanosed, and there is a bluish tinge over 
some other parts of the body. The tongue and gums are quite 
free from this. The child cries constantly, as if from hunger. 

No external malformation. . . . Abdomen not distended, 
but its walls are very tense. On percussion, a tympanitic note 
is got over the region of the stomach, but all over the lower part 
of the belly the note is absolutely dull. The liver and spleen 
cannot be felt. The anus seems small, but admits the little 
finger without much difficulty, and is felt to contain a few soft 
rounded masses. These, when removed by an enema, are found 
to amount to rather more than a teaspoonful in bulk. The 
matter is absolutely without odor, and of a whitish color, with 
no tinge of green or yellow. 

November 20, child died at 7 a.m., aged ten days and four 
hours. On opening the abdomen, a large tumor of purplish- 
red color is found to occupy the greater part of the left half of 
its cavity. This is found to be the distended portion of the 
gut just above the seat of the obliteration. The rest of the 
bowel is found to be contracted to its fullest extent, and is of a 
pale yellowish color. 

Intestines. — At the very commencement of the duodenum the 
gut becomes enormously dilated. The dilated portion measures 
ten inches in length, and from one to one and one-half inches in 
diameter, and is of a dark purplish-brown color. It comprises 
the whole of the duodenum, and probably also a few inches of 
the jejunum. Its lower extremity is an abruptly rounded end ; 
it is perfectly closed, and there is a gap between it and the next 
portion of bowel. The mesentery belonging to it also conies 
to an abrupt end, there being a deep fissure between it and that 
of the succeeding pieces of intestine. The blood-vessels in the 



400 CONSTIPATION IN INFANTS AND CHILDREN 

mesentery are very unusually large. When the distended duo- 
denum is opened, it is found to be full of a turbid yellowish- 
brown fluid, — evidently the food swallowed mixed with bile 
and other secretions. A short distance from the dilated por- 
tion of the bowel is a small bit of gut one and one-fourth inches 
in length, and one-sixth inch in diameter. It is blind at both 
ends (which are rounded), and is fixed in the shape of a horse- 
shoe by a little tongue-like flap of mesentery. 

When the mesentery is followed to the right, its free margin 
is found to be thickened in places by what appears to be frag- 
mentary remains of obliterated bowel, and it is prolonged into 
a peaked flap lying horizontally. From the point of this flap a 
small rounded fibrous band passes in among the neighboring 
coils of intestine, and after encircling the mesenteric attach- 
ment of a large portion of the bowel is fixed by a fan-shaped 
end into the middle of the upper surface of the mesentery of a 
coil of jejunum, about seven or eight inches below the lowest 
point of obliteration. The fibrous band is one inch in length ; 
it is very dense in texture, and resembles fine silkworm gut in 
size and appearance. 

The small intestine becomes pervious again about two and 
one-half inches below the horseshoe-shaped fragment. During 
the rest of its course it varies in diameter from one-eighth to 
one-sixth inch. In one or two situations the lumen is seen to 
be occupied by small masses of green matter; elsewhere it 
seems quite empty. 

The large intestine is similarly contracted, measuring only 
about one-fourth inch in diameter, and is in a similarly empty 
state. 

Case 47. Dr. Greig (Canadian Practitioner, 1892). 

Infant lived four days. . . . 

The stomach and duodenum were healthy and normally 
developed. The rest of the small and large intestines were 
abnormal, and had no connection with the duodenum. 

Extending downward from the stomach, there were about 
two feet of healthy bowel ending in a cul-de-sac. Extending 
upward from the rectum, there were about three inches of 



CONGENITAL CONSTIPATION 



401 



fibrous cord. It was the size of a lead pencil, firm to the 
touch, and on section pervious. Two inches from the upper 
end it dilated, contained fascal matter, and ended in a point. 
There was no connection between the two sections of the bowel. 










Congenital Obliteration of Small Intestines. Case 46, 

2. There may be a gap in the small intestines. 

Cask 48. Imperforate ileum. J. Bland Sutton (American 
Journal of the Medical Sciences, 1889). 

In June, 1889, my friend, Dr. Maxwell, asked me to see a 



402 COXSTIPATIOX IX IXFAXTS AXD CHILDREX 

baby forty-eight hours old, concerning which he furnished the 
following history : The abdomen was found distended shortly 
after birth, and the baby commenced to vomit its food. On 
examining the anus, the parts were found quite normal, and a 
catheter could be passed readily into the bowel for many inches. 
Nothing but mucus passed by the anus. It was clear that we 
had not to deal either with imperforate anus, rectum, or pharynx, 
as the infant could swallow easily, and as it retained milk for a 
time imperforate duodenum was excluded. I therefore came to 
the conclusion that we had to deal with an imperforate ileum. 
At the request of the parents I explored the abdomen, and found 
the ileum imperforate at a spot about eighteen inches from the 
ileo-csecal valve. The distal end of the ileum was somewhat 
shrunken, and separated from the proximal end by a gap an 
inch across. The upper cul-de-sac was dilated with meconium, 
and congested ; this was removed, and the end of the gut 
stitched to the abdominal wound. Meconium and flatus passed 
freely, the child rallied and took food, and the case promised to 
go well, but about six hours later it suddenly expired. 

Case 49. (British Medical Journal, 1886, Vol. 2, 295.) 
Mr. William Thomas exhibited the stomach and intestines 
of an infant five days old that had been operated on for obstruc- 
tion. The stomach was of normal size ; the duodenum became 
gradually enlarged as it reached its termination ; the jejunum 
was very large, and formed dilated coils which had distended 
the abdomen. It had been opened twenty-two inches from the 
pylorus for the relief of the obstruction, and ten inches further 
it terminated in a blind extremity. The small intestine recom- 
menced almost immediately between the layers of the mesen- 
tery, being about the size of an ordinary pencil ; it formed 
several coils, and extending for thirty-six inches, terminated in 
a well-formed ciecum, from which a perfect, though contracted, 
colon could be traced to the anus. The various parts of the 
intestine were so firmly matted together by well-organized 
bands of lymph, the result of previous intra-uterine peritonitis, 
that the relation of the parts could not be made out until the 
intestine was removed from the abdomen. 



CONGENITAL CONSTIPATION 403 

The child was somewhat relieved by the operation, and lived 
for about eighteen hours after it. 

3. There may he no connection between the large and 
small intestines. 

Case 50. J. C. Oliver (Cincinnati Lancet and Clinic, 
August 15, 1891). 

A male child, born in the service of Dr. Allen, developed 
symptoms of intestinal obstruction and died four days after birth. 

Autopsy. — The small intestine was distended so as to 
occupy the entire abdominal cavity. This bulged out as soon 
as the abdomen was opened. Upon tracing the small intestine 
downward from the stomach, it appeared normal until the 
lower end of the ileum was reached, and here we perceived 
that it ended in a blind pouch. Lying immediately below this 
was the free extremity of the large intestine, opening into the 
peritoneal cavity. There was absolutely no connection between 
the intestines at a point corresponding to the ileo-caecal valve. 

Case 51. Carini (Internationale klinische Rundschau, 
Wien, 1890). 

A female child four days old was brought to the hospital for 
outdoor treatment. The child suffered from intestinal ob- 
struction, having had no evacuation since its birth. 

*********** 

The small intestines end in two blind pouches, consisting of 
thin loops having the macroscopic form of the intestine ; they 
look like two diverticula of the small bowel, and do not com- 
municate with the large intestine. A further loop is connected 
with the umbilicus ; it represents a Meckel's diverticulum. 
The large bowel is free from faeces. It begins in a blind loop, 
the calibre of which progressively increases until it reaches the 
normal diameter. The rectum, of normal length, is imper- 
meable at the upper halt* ; the lower half is dilated and of a 
dark-red color, due to numerous ecchymoses into the mucous 
membrane. 

A slight laceration at the anal extremity. 



M 



404 CONSTIPATION IN INFANTS AND CHILDREN 

4. The whole digestive tract from the stomach down may 
he disconnected. 

Case 52. Total occlusion of the coecum. Rudimentary pan- 
creas. Absence of duodenum. Jejunum ending in a cul-de-sac. 
JVo connection between stomach and small intestines and intes- 
tines and gall bladder. Ill-developed colon in new-born infant. 
O. A. Fliessburg (Northwestern Lancet, 1891). 

The child was in all respects as large as a foetus of nine 
lunar months, seemingly well developed, and cried lustily soon 
after birth. . . . The next day everything seemed all right, 
but the nurse told me the baby had not yet had a movement. 
I inspected the child and found nothing out of the way, except 
that it had a poorly developed mouth and could not nurse. . . . 
It lived one hundred and eighteen hours before it died. 

At the autopsy, eighteen hours after death, the following 
conditions were found. . . . On opening the abdominal cav- 
ity, I found at once the place of obstruction ; it is situated at 
what I think to be the cecum, or it may be the ileum ; the 
intestines were very strongly matted and glued together into a 
pj'ramiclal coil. There was no connection to be found between 
the upper viscera and the smaller intestines. . . . 

The condition of the intestines is already described in the 
title. 

5. Tliere may he a congenital stricture located in any one 
of the sections of the small intestine. 

Case 53. Congenital stricture of the duodenum. J. H. 
Emerson (Archives of Pediatrics, 1890). 

Infant born April 24, 1890, after normal labor. It weighed 
eight and one-half pounds and appeared well until thirty hours 
old, when it spat up one-half ounce or more of dark blood 
mixed with mucus. . . . 

There was a dark, tarry stool. The child evinced no desire 
for food ; there was no evidence of suffering except when raising- 
blood, which caused some gagging. There was no cough, no 
fever, no disturbance of respiration, nothing found on physical 



CONGENITAL CONSTIPATION" 405 

examination of the fauces, etc. Another stool contained only 
meconium, no blood. 

Post-mortem examination showed the stomach markedly 
dilated, the pyloric orifice two centimetres , in diameter; the 
duodenum markedly distended, but terminating abruptly just 
above the orifice of the common bile duct. Fluid could not 
be forced from the stomach below this point, nor could air be 
forced upward from the intestine to the stomach. 

Case 54. Stricture of the duodenum. Grimsdale (Liver- 
pool Medico-Chirurgical Journal, 1892). 

A few months ago a midwife told me that she was expecting 
shortly to attend a woman in her confinement who had pre- 
viously had five children ; one of these was still born, and the 
remaining four had all died on the third day, . . . and it was 
supposed that they had died because the valves of the heart 
had not closed. On August the 6th the child was born, and 
I accordingly went to see it. The child was a well-formed boy 
and looked healthy and well nourished. I examined him and 
could find nothing whatever wrong. . . . The child had 
passed water, and the bowels had acted. All seemed to go 
well for the first two days, but on the third day the child took 
a slight convulsion and vomited a little. 

*********** 

I examined the abdomen again and again, and found it quite 
flaccid, and apparently no tenderness over it anywhere. The 
bowels were acting frequently, the motions being still meco- 
nium. The child had only vomited once, and then only slight, 
according to the account of the relations. There was therefore 
nothing on which to diagnose obstruction. ... On the fourth 
morning I again saw the child, and found that it had convul- 
sions. It was in almost exactly the same state as on the pre- 
vious evening, and I was as much in the dark as ever. I ought 
to mention that the child was taking the breast regularly. On 
the evening of the fourth day I had a message to say that the 
child had another convulsion. I went down at once to see the 
child and found it dead. There was a large quantity of black 



406 CONSTIPATION IN INFANTS AND CHILDREN 

vomited matter, which looked like milk mixed with meconium 
or semi-digested blood. The next day I made a post-mortem. 

The stomach and duodenum were much dilated ; the rest of 
the intestines were quite small and cord-like. I removed the 
stomach and intestines, and found that there was an occlusion 
of the gut situated about two inches from the pyloric end of 
the stomach, just above the opening of the bile duct. This 
entirely obliterated the intestine, the duodenum terminating in 
a cul-de-sac. 1 

6. The obstruction may be due to a membranous dia- 
phragm projecting into the lumen of the bowel at one or 
more points. 

Case 55. F. Charlewood Turner (Transactions Pathologi- 
cal Society, London, 1887). 

A female infant died on the fourth day. About the middle 
of the jejunum a portion of the canal, about an inch in length, 
was found shut off* from the parts above and below by mem- 
branous diaphragms. It contains a small quantity of mucous 
secretion which cannot be pushed past either boundary. The 
bowel above is greatly dilated ; that below is contracted. 

Case 56. Grawitz (Virchow's Archiv, Vol. 68 2 ). 

Child died eight days after birth. The jejunum is dilated 
to almost colossal dimensions (see cut) by the accumulation of 
masses of meconium and gases. It extends to the point a, a 
point of constriction, and which presents the appearance as if 
the adjoining and narrower section of the IL 1 (ileum) were a 
strange body soldered on to the larger ; nevertheless the walls 
are continuous, and the constriction furrow at a denotes the 
point at which a membranous diaphragm projects into the lumen 
of the tube, and cuts off to a considerable extent the free inter- 

1 See also Rosenkranz, Max, Em Fall angeborener Stenosirung des Diinn- 
darms u. Dickdarmes nebst defekt einer Niere, Konigsberg in Prussia, 1890. 
Index Medicus, 1890. 

2 Dr. Paul Grawitz, Ueber den Bildungsmechanisnms eines grossen Dick- 
darmdivertickels. 



CONGENITAL CONSTIPATION 



407 



communication between the parts, the opening remaining not 
being larger than a lentil. This membrane, which shows 
through on the dry preparation, is exactly like the diaphragm 
of a microscope. Through its round central opening, meconium 



J, Jejunum, a, Point of junction of jejunum and ileum, — 
membranous diaphragm with a perforation at this point. II 1 , First 
jli section of ileum, b, Point where second complete membranous dia- 

phragm is found. II 2 , Further section of ileum. 

masses passed into the following section, the 
IL\ and effected here also a dilatation to more 
than three times the normal calibre, as shown by 
IU 1 . This second section reaches to the point 
6, at which another constriction furrow presents. 
At this point another membranous diaphragm 
projects into the canal, and cuts off completely 
all communication between the parts above and 
those below. The rest of the small bowels and 
the large gut (which does not appear in the figure) 
are empty and very narrow, especially in compari- 
son with the jejunum. 

7. There may he a stricture at one point and an obstruct- 
ing diaphragm at another. 

Case 57. Demme (Wiener mediz. Blaetter, 1884). 

Girl four months old. It was not till the fourth day after 
her birth that she had an evacuation of meconium of brownish- 
gray color and of mortar-like consistence. From this time on 
the child had an evacuation only every two or three days, later 
on only four or five days. May 2, 1882, at the expiration of 
her third month, a protracted obstruction with progressively 
increasing meteorism set in. May 9, the seventh day of the 
obstruction, an icteric discoloration of the skin and conjunctiva 



408 CONSTIPATION IN INFANTS AND CHILDREN 

is noted, and she vomits every ten or fifteen minutes a thin 
watery fluid. The infant refuses all nourishment, and will 
take nothing but one-half to one teaspoonf ul of ice-water from 
time to time. With the exception of warm moist abdominal en- 
velopments, lukewarm baths, and rectal injections, no treatment 
is possible. May 10, as on the preceding days, three-fourths 
of a litre of lukewarm water was injected into the rectum by 
means of the rectal tube, with funnel and elevated position of 
buttocks. After the discharge of the water, a great mass of 
thin fasces of grayish color and horribly offensive was evacu- 
ated with an abundance of flatus. Three hours later the essen- 
tial symptoms had disappeared. The temperature in the rectum 
had fallen to 37.4° C. (99° F.) ; the abdomen had become soft ; 
the vomiting was arrested. By the daily administration of 
small doses of castor oil, a daily evacuation of faeces was ob- 
tained up to May 20. The mother having lost her milk, the 
child was fed with condensed milk properly diluted. May 20, 
obstruction has again set in with vomiting and persistent and 
harassing singultus. The treatment employed was large injec- 
tions of water. May 26, no evacuation to date ; continuous 
vomiting of fsecal matter to-day. The little patient died at 
6 p.m., after complete exhaustion of her vital forces. 

On opening the abdomen, there was found a superficial agglu- 
tination of the intestinal loops by thin, yellowish-red fibrous 
bands. The peritoneal covering of the various sections of the 
bowels was but moderately injected, and then mainly in the* 
form of little islets. On taking out the bowels, the various 
sections appeared, as was already seen whilst they were still in 
situ, rather unequally dilated. The duodenum was dilated to 
sack-like dimensions, and filled with meconium and gases. In 
the collapsed jejunum there were found at the borders of the 
duodenum and of the ileum points of constriction from three to 
five centimetres in length. Laid open, the tissues at these two 
points were found tough and cord-like, and the lumen so nar- 
rowed that only a very thin lead pencil could pass through. 
The jejunum was furthermore almost completely cut off from 
the ileum by a crescentic fold of mucous membrane, which pro- 



CONGENITAL CONSTIPATION 409 

jected like a diaphragm into the lumen of the canal. The 
cord-like points of constriction, especially the one between the 
duodenum and the jejunum, were covered with fibrinous exu- 
dations. The mucous membrane of the duodenum was dis- 
colored blackish-green, was tumefied and soggy, friable, but 
nowhere torn. The ileum, ceecum, and colon were collapsed 
and almost empty ; the mucous membrane was pale. 

Treatment. — The treatment of constipation dependent 
upon malformations, where treatment is possible, is en- 
tirely surgical, and the details thereof can be found in 
extenso in the work of Bodenhammer referred to, in the 
works on the diseases of the rectum, and in the various 
treatises on surgery. 

Here I would only call attention to these two points : 

(a) Narrowing of the oriftcium ani can be very properly 
treated by dilatation. 

(b) In a case in which the rectum was obstructed by 
two membranous diaphragms, Lannelongue succeeded in 
perforating the upper through the artificial anus which he 
had established, and cut out the lower one by an incision 
from the exterior and the natural passage for the faeces 
was thus re-established. 1 

Case 58. Lannelongue (Observation II.). 

May 24, 1882, there was brought to the hospital Trousseau a 
new-born infant of the male sex, fifty-two hours old at the time 
of the examination. He is the second son of healthy parents, 
and there is no evidence of any syphilitic antecedents in the 
parents. The infant is lively, urinated easily, but has not 
passed any meconium since its birth. It is otherwise well 
formed. Examination of the anal region : nothing particular 

1 Lannelongue, Sur une Variete Rare de Malformation Congenital? de la 
Region Ano-rectale. Bulletin et Memoires de la Societe de Chirurgie^ 1884. 
Virchow und Hirsch, Jahresberichte, 1884. 



410 CONSTIPATION IN INFANTS AND CHILDREN 

is seen ; the anus and its folds are normal ; the finger introduced 
therein passes into an infundibulum two to three centimetres 
in depth. It is rather difficult to introduce the finger, and 
when the infant cries or weeps, no sort of impulse is felt. A 
careful examination excludes the existence of a rectal ampulla. 
The belly is distended ; the abdominal parietes are not cedema- 
tous ; the intestinal loops cannot be seen outlined upon the 
abdominal wall. 

The infant is operated upon after the method of Littre ; the 
gut is found beneath loops of small intestine. It is stitched to 
the abdominal parietes ; it is opened, and a great quantity of 
fseces or meconium flow out. The intervention has been a 
happy one ; a good nurse is secured, and the child is brought 
to us at first every day, then every second or third day. The 
15th of June : the opening in the abdominal parietes began to 
be the seat of a retraction process ; there is a simple erythema 
all around it, provoked by contact with intestinal matters. 
June 18 : the artificial anus is well constituted ; the cutane- 
ous orifice is rounded, and permits of the passage of the finger. 
At the bottom there is felt a slight projection of mucous mem- 
brane. I took a uterine sound and directed it to the lower end 
of the opening. It was promptly arrested at about two to three 
centimetres from the cutaneous orifice ; there was an obstacle 
which looked to me as if it were the termination of the intestine. 
As I was endeavoring to discover the distance which separated 
it from the anus, which was really rather great, it seemed to 
me that the resistance I had encountered yielded, although I 
made but very moderate pressure. A little stronger effort, and 
the sound entered the pelvic cavity ; it was too short to reach 
the anus, so I took one of Chassaignac's long curved trocars, 
and with a great deal of care introduced it by its blunt end. It 
stood out rather prominently at the summit of the infundibulum 
of the anus, and I could feel it with the finger introduced into 
the infundibulum from below ; a very slight thickness separated 
the point of the trocar from the summit of the infundibulum ; 
it would have been possible by proceeding with some violence 
to pass this separation. 



CONGENITAL CONSTIPATION" 411 

I concluded, nevertheless, to proceed otherwise. A posterior 
incision was made, beginning at the anus, down the median 
line, toward the point of the coccyx, about one and one-half 
centimetres in length ; the skin, the underlying tissue, were 
successively incised, and finally the obstructing membrane 
itself was cut on the instrument. A drainage tube of large 
calibre, reaching from the natural to the artificial anus, was 
inserted, and allowed to remain. Two sutures reunited the 
perineal incision. It was also advised that an injection of a 
weak solution of boracic acid be made daily through the tube 
so as to cleanse it. 

June 19 : the child is in excellent health ; he has passed 
fsecal matter through the cavity of the tube. Two days later, 
June 21, the drainage tube w r as taken out to be cleansed; a 
rather large sound is introduced into the rectum, and passes 
readily beyond the lower obstacle. The drainage tube is 
replaced ; the opening of the ^artificial anus will barely admit 
the tip of the finger. 

June 23 : sutures taken out ; no inflammatory engorge- 
ment ; every day, fsecal matter passes through the large tube. 
June 26 : drainage tube withdrawn and cleansed ; rectal sounds 
of graduated calibre are passed ; the drainage tube is replaced, 
and allowed to remain to the 29th. At this date large quanti- 
ties of fsecal matter passed out through the artificial anus. The 
infant is seen again July 2 ; the mother is advised to pass daily 
the rectal sounds through the normal anus. 

An enteritis with frequent and abundant diarrhceal dis- 
charges sets in, and since the night before the child looks bad, 
very much exhausted. Since then I have not seen our little 
patient, and I have all reason to believe that it has succumbed. 

Chronic Constipation. — Certain congenital malforma- 
tions (Shelf, perforated or incomplete diaphragm, etc.) 
may be the cause of a chronic constipation that lasts 
throughout life. It usually manifests itself first at a later 
period, at a time when the faeces become firm in consist- 
ence and abundant in quantity. See Part L, Chap. VII., 
and Part II. , Chaps. III. and V. 



CHAPTER II 

ACQUIRED CONSTIPATION 

I. Acute Constipation 

The term " acquired constipation " explains itself. It 
means that this form of constipation is acquired by the 
little patient through some fault or neglect on the part of 
the parent or nurse, or as a consequence of some morbid 
process developed subsequent to its birth, and that, in 
contradistinction to the form previously considered, it is 
not due to any inherent vice of anatomical conformation. 

The acquired constipation of infants presents itself to 
us in one or other of two forms already named ; viz., 

I. Acute constipation. 

II. Chronic constipation. 

m, «ii. «ii. <iL. *!£. **£. »A£. «i^. *!£. -i/-. <&l~ 

Acute Constipation. 

Acute constipation has been already defined elsewhere 
and needs no further elucidation here. It is caused in 
infants by : 

Intussusception, volvulus, strangulation through a slit 
in the omentum. 

Strangulation by bands. 

Hernia (inguinal, femoral, or umbilical). 

Paralysis of the intestine consequent upon traumatic 
injury of one or more loops. 

412 



ACQUIRED CONSTIPATION 413 

Case 59. In January, 1875, I was called to see Mary B. in 

consultation with Dr. . The little patient, cet. five years, 

was in bed, presented an emaciated appearance and a counte- 
nance expressive of much suffering. She was ill now four days. 
The history, as given me, was that she had complained of pain 
in the belly and about the loins, had had considerable fever, 
vomited frequently, complained of headache, and was thought 
to have had some delirium at times. For various reasons the 
physician in attendance had diagnosed the onset of smallpox 
(the disease was then prevalent) and had prescribed a laxative. 
This proved ineffective, and a stronger purge was ordered ; 
this also had no effect. In fact, the child was obstinately con- 
stipated, despite all the measures taken to produce an evacuation. 
The vomiting had abated since the third day, though the 
child took nothing more than a little milk and water, and of 
this but a teaspoonful or two at a time. 

Examining the little patient, I found the belly very tender 
in a limited region about the umbilicus and upward toward the 
large bowel, and so sensitive was this part that she cried out 
upon the slightest touch. The thighs were flexed upon the 
pelvis, and the legs upon the thighs ; upon the slightest attempt 
to straighten out a lower limb, she cried with pain. The tem- 
perature was 101° F.; pulse very rapid and feeble. Upon 
questioning the mother very closely about the onset of the 
illness (as I failed to recognize any evidence of approaching 
variola), I learned that on the afternoon of the Sunday pre- 
vious the child had been sent out to get some beer. In going 
to the saloon, she stepped upon an iron cellar door, which she 
had failed to see owing to the snow that covered it, slipped, 
and fell upon her belly. She complained of some pain on her 
return home. That evening she vomited rather frequently ; 
the pain grew much worse as the night progressed, but abated 
considerably toward morning. 

My diagnosis was traumatic injury of some portion of the 
intestinal tract, and most probably of a portion of the small 
bowels. 

The efforts at purgation were at once suspended. Opiates 



414 CONSTIPATION IN INFANTS AND CHILDREN 

were prescribed ; hot fomentations to the abdomen and small 
rectal injections of very warm water were ordered. 

The child continued to grow worse, and died on the eighth 
day of its illness. 

I was very anxious for a post-mortem view, and by means of 
a ruse-de-guerre I succeeded in obtaining permission to open 
the belly in the presence of a relative. Post-mortem twenty- 
eight hours after death. Body almost frozen. The parietal 
peritoneum presented nothing abnormal ; cutting this, and 
turning it aside, we found right before our eyes a loop of the 
small bowel that presented a mortified appearance. It was 
of a dark rusty color with streaks of green here and there. 
Only this single loop was affected ; the other parts of the 
intestinal tract and other abdominal organs were apparently 
healthy. 

Acute diseases of the small bowels (duodenitis, enteritis). 

Acute diseases of the large bowel (typhlitis, appendi- 
citis }. 

Acute diseases of the liver. 

Inflammation of the peritoneum. 

Acute diseases of the brain and spinal cord. 

The modus operandi of these various factors has been 
set forth in Part I. 

Acute constipation may be caused furthermore by : 

Foreign substances swallowed in sufficient quantity to 
obstruct the lumen of the bowl. 

Children usually swallow the stones of fruits (as of 
cherries, plums, etc.), or the seeds thereof (as of grapes), 
with the fruit itself, and if these be in any quantity they 
will pack together, and obstruct the passage through the 
bowel. Occasionally food or the parenchymatous portion 
of the fruit swallowed insufficiently masticated, in chunks, 
may cause the obstruction. 



ACQUIRED CONSTIPATION 415 

Case 60. A. H. Watkins (Lancet, London, 1885, Vol. I., 
p. 457). 

A boy ten years of age was brought to me by his mother, 
saying he was suffering from constipation of four days' dura- 
tion. As the patient walked with difficulty, and complained 
of a great deal of pain about the anal region, I made a local 
examination, and found the anus loose and flabby, and occupied 
by a hard, dense mass of fig pips, of which a good number were 
adherent to the buttocks. Finding it impossible to introduce 
an enema tube, I proceeded to remove the mass by scraping 
away with the fingers, the relaxed condition of the anus readily 
admitting two fingers, though the acute pain that the patient 
suffered made it necessary to administer chloroform. I re- 
moved in this way half a pound (weighed) of fig pips, besides 
many which were washed out afterwards by an enema. The 
whole bowel for several inches seemed quite paralyzed by the 
distention to which it had been subjected. On the following 
day the patient seemed quite comfortable, and the bowels had 
acted. As I have heard nothing of him since, I presume he is 
well. 

The following case reported by Townsend (Annals of Gynaecology and 
Pcediatry, March, 1897), is of the greatest interest, as it seems to show that 
foreign bodies may penetrate through the abdominal parietes into the 
abdominal cavity and cause acute obstruction. This is really not to be 
wondered at, when we remember how much children crawl around on the 
floor and on the ground among the poorer and middle classes, and how 
frequently needles, pins, etc., are scattered about, and how very often the 
flooring is of the roughest boards. 

Case 61. For several months past the child had attacks of crying as if 
in pain, and the mother, supposing them due to colic, paid but little atten- 
tion to them. Suddenly the symptoms grew more urgent, the abdomen 
became swollen, incessant vomiting set in, and the now alarmed mother 
brought the child to a physician, who sent him to the hospital for opera- 
tion. On examination a tense, painful tumor was noticed just to the 
left of the umbilicus. From this, in conjunction with the symptoms, a 
diagnosis of acute intestinal obstruction, due probably to an incarcerated 
umbilical hernia, was made, and the child was immediately operated upon. 
On incising over the swelling the knife passed through a dense inflam- 
matory exudate thrown out into the left rectus muscle ; upon further inci- 
sion the abdominal cavity was opened, disclosing the inflamed intestine 



416 CONSTIPATION IN INFANTS AND CHILDREN 

adherent for some distance to the abdominal wall. On separating the 
adhesions a pine splinter, about one inch long, was found — one portion em- 
bedded in the abdominal wall, and the other protruding into the intestinal 
canal. . . . 

Worms. — J. Lewis Smith 1 relates the case of a girl 
four years of age in whom acute constipation developed 
suddenly, and was accompanied by distention of the 
abdomen and great suffering. This continued nearly one 
week, when a mass of intertwined worms was expelled 
with immediate relief. 

A large gall stone, which will obstruct the ileo-csecal 
valve, may be the direct cause of an acute constipation. 

The diagnosis of acute constipation is rather the diag- 
nosis of the morbid condition of which it is but one of the 
symptoms, whether this be some grave pathological pro- 
cess or some foreign body that can be readily removed. 
So far as the former is concerned, the differential diag- 
noses can be found in detail in the various treatises 
already referred to. As regards the latter, a careful 
inquiry as to the mode of onset of the attack and the 
conditions of the child and events just preceding it ; a 
history of the habits of the child, its amusements, its diet 
and manner of eating, its supervision ; . and a careful ex- 
amination of the rectum, — may, and in great majority of 
cases will, lead to its recognition. 

The treatment will be found in the special books upon 
the various topics and the large general treatises. I 
would only call attention once more to what I advocated 
in my article on " Intestinal Obstruction," 2 that in all 
cases where w r e may have reason to suspect a sudden 

1 Diseases of Children. 

2 American Journal of the Medical Sciences, January, 1886. 



ACQUIRED CONSTIPATION ' 41 7 

obstruction of the intestinal canal, large massive enemata 
should be immediately resorted to, for the reason that they 
have a marked and rapid curative effect, and if they fail 
we know at once that operative interference is necessary, 
and that it should be resorted to without delay. 



CHAPTER in 

II. CHRONIC CONSTIPATION 

For the purposes of a clearer understanding and a better 
comprehension of the therapeutic indications, this cate- 
gory of our subject is divided into two groups, namely : 

I. Chronic Constipation, dependent upon an abnormal 
condition of one or more organs or parts of the body. 

II. Habitual Constipation, due to functional disturb- 
ance. 

Chronic Constipation 

Chronic constipation may be due to some congenital 
malformation of the intestinal tract, as has already been 
indicated, or it may be produced by any of the various 
pathological conditions which give rise to it in the adult, 
and which have already been enumerated in a previous 
chapter. 1 

Case 62. Cancerous growth pressing upon the rectum. 
Thomas Smith (Transactions Pathological Society, London. 
Vol. 19). 

The specimen was removed from a child, aged fourteen 
months, under Mr. Smith's care at the Children's Hospital. 
Two months before admission the mother noticed that the 
child had difficulty in passing the motions, and soon afterward 
that it strained when passing water, and that occasionally the 
urine dribbled away. These symptoms increased in severity. 

1 See Part I.. " Chronic Constipation." 
418 



CHRONIC CONSTIPATION 419 

and the child seemed at times to have pain in the belly. A 
month ago a hardness and swelling were noticed in the lower 
part of the abdomen ; they have gradually increased. A 
month ago retention of urine came on, which, was relieved by 
the catheter. At no time has any blood been seen. . . . 

The tumor felt during life proved to be a large, malignant 
growth springing from the recto-vesical pouch, filling the 
pelvis, and growing upward into the abdomen behind the 
bladder, which was greatly elongated, especially about the neck, 
the fundus lying above the level of the umbilicus. The coats 
of the bladder were greatly hypertrophied, but otherwise 
healthy. 

The tumor was partly solid, but in the upper part were 
numerous cysts containing a semi-fluid substance. 

Anal fissure is regarded by Gautier, 1 of Switzerland, as 
a frequent cause of chronic constipation in the new-born. 
J. Lewis Smith 2 says that it is of rare occurrence then, and 
in this, taking the term " new-born " in its stricter sense 
(to a month or six weeks), my own experience fully con- 
firms him. At a later period, however, in later infancy 
and early childhood, it is of more frequent occurrence, as 
was already noted by A. Jacobi, 3 and is many times the 
unsuspected cause of the general fretfulness, of the par- 
oxysms of crying, of the sleeplessness of the child. 

Excoriation of the Anus. 

Case 63. Boy, cet. three and one-half years, stout, rather 
robust-looking little chap. His mother complains that every 
evening at six he begins to cry, and continues to do so almost 
without cessation until twelve midnight. When the pain or 
crying spell comes on, he will not sit or lie quiet. He is 
continually changing his position. There is, according to 

1 Quoted by J. Lewis Smith, Diseases of Children. 

2 Diseases of Children. 

3 Intestinal Diseases of Infancy and Childhood. 



420 CONSTIPATION" IN INFANTS AND CHILDREN 

her statement, nothing abnormal in the stool ; the urine is 
normal ; there is no fever. 

He was closely examined, but nothing at all could be found 
that would account for the crying spells. 

Persistent inquiry elicited that the boy did not pass his 
urine well, that it dribbled away, but that in the morning, on 
arising, he passed a fairly large quantity. 

It was also learned that the boy was costive, and, finally, it 
was disclosed that the crying spell coincided with the time 
when the little fellow was placed on the vessel. 

Examining now the anus by drawing the nates well apart, 
I found the sphincter excoriated, sore, inflamed all around, and 
coated with pus. The excoriations and inflamed condition 
extended up some distance. 

Tubercular Peritonitis may cause Chronic Constipation. 

Case 64. J. Lewis Smith. 1 

Charles, cet. four years, was returned to the New York 
Foundling Asylum on April 16, 1877, to be treated for tumor 
albus of the left knee, and for general ill health. His parent- 
age and early history were unknown. The nurse in the city, 
to whom he had been entrusted when quite small, stated that he 
had had no sickness when with her except sore e}^es, and that 
about April 1, 1877, the enlargement of the knee was first 
observed. The head of the boy was large, and the abdomen 
much distended, but without any decided tenderness on press- 
ure ; its entire lower part had a purplish color. Percussion 
over it gave a dull sound except upon and near the epigastrium, 
where there was some resonance ; umbilicus prominent ; cir- 
cumference of body over abdomen, twenty-three inches ; pulse 
128 ; axillary temperature, 99° F. It was stated that he had 
no stool without medicine, and that usually one tablespoonf ill 
of castor oil was required to produce it. The urine contained 
no albumen, and was apparently normal. As the appearance 
indicated struma, a mixture of cod-liver oil, syrup of the lacto- 
phosphate of lime, and iron was prescribed to be given three 

1 Loc. cit. 



CHRONIC CONSTIPATION 421 

times daily, and directions were given to rub cod-liver oil over 
the abdomen also three times each day for five minutes each 
time. Some nodules were felt on pressure upon the abdomen, 
which was suspected were enlarged mesenteric glands. From 
the day on which the friction and kneading' of the abdomen 
were commenced, the stools began to occur on the average 
about twice daily. The kneading proved the safest as well as 
the most efficient method of producing defecation. On May 4, 
the circumference of the trunk over the most prominent part 
was reduced to twenty-six inches. The records on May 11 
state, " Same treatment continued ; has tolerable appetite, but 
is pallid, and his flesh flabby and soft." From this time he 
gradually failed, and died April 11, 1878. 

Autopsy. — Lungs healthy, except a little exudation over the 
summit of right lung ; bronchial glands cheesy ; numerous 
tubercles, some of them cheesy, upon the parietal and visceral 
surface of the peritoneum. I^oops of the intestines were united 
to each other by old adhesions, and the small intestines were 
generally bound down by bands into a " uniform conglomera- 
tion " ; mesenteric glands, enlarged and cheesy ; a large ulcer 
upon the surface of the rectum, and numerous small, round 
ulcers upon the surface of small and large intestines apparently 
occupying the site of the solitary follicles. 

Chronic hydrocephalus is always accompanied by a 
chronic form of constipation. 

Rachitis induces chronic constipation (debility of the 
muscular coat). 

As to the diagnosis and treatment. , what has been said 
in the preceding chapters applies here also. This may be 
said in addition, that in the cases of chronic constipation 
dependent upon congenital malformations a correct diag- 
nosis as to the exact condition present will be almost 
impossible (diaphragm in the rectum excepted). 



CHAPTER IV 

HABITUAL CONSTIPATION 

The normal infant has from three to four evacuations, 
rarely five, in the twenty-four hours. The reason for this 
frequency is that the simple aliment of the infant is very 
rapidly elaborated into the proper condition for absorp- 
tion, and that in order to be quickly absorbed it passes 
very rapidly over the whole intestinal surface, through 
the canal. 

The discharges, which are made up of undigested fatty 
matter, epithelial cells, detritus from the intestinal canal, 
intestinal mucus, and coloring matters from the bile, are 
yellow in color and of pap-like consistency, thinner in 
breast-fed, thicker in hand-fed infants; with no peculiar 
odor ; occasionally they have a slightly sour smell. 

Under certain influences, by which the peristaltic func- 
tion of the intestinal canal is disturbed, the discharges are 
retarded, diminished in number, and reduced to one a day, 
one every other day, or what is of more rare occurrence, 
one in three or four days. 

The disturbance of peristaltic function may be in the 
nature of : 

(a) An impairment of physiological action, — - atony of 
the intestine. 

422 



HABITUAL CONSTIPATION 423 

(b) A perversion of the physiological action, — spasm 
of the intestine. 



Habitual Constipation due to Atony 

An atony of the intestine may result from a variety of 
causes ; it may be due : 

1. To maternal influences. 

2. To drugs. 

3. To faulty alimentation, to improper feeding. 

4. It may be the consequence of a preceding intestinal 
catarrh. 

1. To Maternal Influences. — Much observation has 
shown that the infants of constipated mothers are them- 
selves constipated, or have a marked inclination thereto. 
In my own experience I have seen infants who from the 
very earliest period of infantile life (after the third day, 
when the secretion of the mother's milk properly begins) 
did not have more than one stool per day, and that of a 
consistency much firmer than usual. In these cases an 
investigation as to the habit of the mother disclosed the 
fact that she was generally constipated. 

Whether this is due to an inherited sluggishness of the 
intestine or is dependent upon the mother's milk is still a 
question. Vogel 1 states that the milk of the mother was 
examined, and nothing at all abnormal found therein. 
In a few cases in my own practice where for one reason 
or another the mother's breast had to be given up, and 
artificial feeding resorted to, considerable improvement 

1 Diseases of Children. 



424 CONSTIPATION IN INFANTS AND CHILDREN 

followed. In some other cases where the mother was 
treated for the constipation and relieved, the infant was 
also much improved. These facts would seem to indicate 
that it is rather the milk which, partaking of the nature 
of the person secreting it, is binding. 

2. To Drugs. — It is well known that brandy, whisky, 
or crin are given to infants in innumerable cases, and 
almost from the first hour of extra-uterine life. With 
many mid wives, nurses, and good old ladies it is thought 
impossible to raise a child without the occasional use of 
these alcoholic stimulants. In other innumerable in- 
stances resort is had to stronger agents, the opiates, which 
are administered in the form of paregoric or soothing- 
syrups. The purposes of such administration are sup- 
posedly to relieve colic, but very much more frequently 
to put the baby in a stupor, and keep it from crying 
whilst the mother or nurse are elsewhere, and, for them, 
more pleasantly engaged. 

The result is a constipation more or less obstinate, and 
a very dyspeptic stomach. 

3. To faulty alimentation. 
To improper feeding. 

A. The Breast Milk. — (a) The breast milk may con- 
tain too great a percentage of casein and too small a 
quantity of fat. 1 In the early period of infantile life the 
efforts at digestion of too great a quantity of solid matter 
and the carrying forward of it soon exhausts the strength 
of the intestinal muscle, and inertia follows. 

(b) The milk may be deficient in the percentage of 

1 Widerhofer, Gerhard's Handbuch d. Kinderkr.. Bd. -i, Th. 2, article 
"Obstructio Alvi." 



HABITUAL CONSTIPATION 425 

sugar. 1 It is claimed that lactose, or milk sugar, stimu- 
lates peristaltic action, i.e. that it has some mild laxative 
properties ; a milk deficient therein would naturally be- 
come somewhat binding. - 

Though one or the other of these defects in the mother's 
milk may occasionally account for the constipation, still 
in the majority of cases nothing will be found therein on 
the most careful analysis, and only the constipation of 
the mother will explain the constipation of the infant. 

B. Artificial Foods. — I. Cow's milk, when given insuf- 
ficiently diluted, does, in many cases, produce constipation, 
especially in the cooler months of the year. The hard, 
firm coagulum of the cow's milk taxes all the strength of 
the intestinal tract, both as to its digestion and transpor- 
tation, and atony from the stomach down follows. 

It may be also that a sort of packing of the canal by 
the milk coagula causes the constipation. 

II. The various infants' foods have all been accused of 
constipating, more or less, the infants fed upon them. 

III. At a later period, the feeding with amylaceous 
articles — bread, tapioca, arrowroot, potato pap, corn- 
starch — tends to constipate. 2 

Improper Feeding. — There is one factor that I hold 
more responsible for constipation in the cases of children 
fed with cow's milk (and not infrequently in the case of 
breast-fed children) than the casein, and that is improper 
feeding. It is strange, but nevertheless true, that many 
mothers seem to believe that a baby's stomach is made of 
some elastic material, that you can put any quantity of 

1 Jacobi, "Constipation in Infants," American Journal of Obstetric*. L869. 

2 Widerhofev, loc. cit. 



426 CONSTIPATION IN INFANTS AND CHILDREN 

food into it, and that the more you put in the better it is 
for the baby. I have already called attention to this 
point in my article on " Summer Complaint," * and my 
experience there has been verified here. Infants are fed 
every half hour ; in fact, every time the baby cries the 
breast or bottle is pushed into its mouth. One hour is 
really a very long interval. When, however, the physi- 
cian asks how often do } 7 ou nurse the baby ? he will, as a 
rule, be glibly answered, "Oh, every two hours"; only 
after careful cross-questioning will the truth be disclosed 
that instead of once every two hours, the infant is fed 
twice (and I have known cases where it was thrice) every 
hour. 

Then as to quantity. Others, though they observe the 
regulations as to time, will disregard those as to quantity. 
I know of instances where babies two or three months old 
were given six to eight ounces of food at each feeding. 

These sins of omission and commission, to which the 
general practitioner as a rule pays but little attention, do 
not pertain to the lowly alone, but are found amongst the 
most refined and educated of our people, even among 
medical men in their own families. 

This overfeeding, whether of frequency or quantity, 
produces an atony of the stomach (where proper attention 
is not paid to cleanliness a catarrhal condition is devel- 
oped), and as a result we have constipation, just as we 
have it with atony or catarrh of the stomach in the adult. 

Sometimes as a result of the large quantity of flatus 
developed in these cases of overfeeding, we have portions 

lu Summer Complaint, A Clinical Contribution to the Etiology, Pathol- 
ogy, and Treatment of the Disease," New York Medical Journal, 1892. 



HABITUAL CONSTIPATION 



427 



of the intestine distended beyond measure, and other parts 
of it paralyzed, as it were, as already described elsewhere. 

Again, we may have a perversion of peristaltic action in con- 
sequence of a hyperirritation produced either by the masses of 
alimentary matter or by the gases ; namely, spasmodic contrac- 
tion of the intestine (generally with more or less pain, excep- 
tionally without it). 

4. It may he the Consequence of a Severe Catarrh. — 
Severe catarrh of the intestinal tract is frequently fol- 
lowed by constipation. The exaggerated action during 
the catarrhal period exhausts the normal vigor of the 
muscular coat, and leaves it in an atonic state. The 
secretory apparatus in the mucous membrane becomes like- 
wise impaired, and, owing 'to this impairment and the 
atony of the muscular coat, the secretion of mucus, so 
necessary for the proper onward movement of the mate- 
rial in the canal, is deficient in quantity, and perhaps also 
in quality. 



CHAPTER V 

HABITUAL CONSTIPATION DUE TO ATONY {Continued) 

Other Causes 

Besides the palpable and clearly recognizable causes 
which have been set forth, there are others which are 
counted as among the factors of habitual constipation ; 
some, whose relationship is very questionable, others, not 
recognizable. 

I. Insufficiency of food. This, as has been already 
explained elsewhere, cannot be regarded as a cause of 
constipation. The infrequency of faecal discharges, the 
result of insufficient food, is not constipation. 

II. The too great length of colon cannot, with all due 
deference to the eminent gentleman who suggested it, 1 
be considered a cause of habitual constipation. There 
is not the least evidence therefor. In the one case re- 
ported in support, the constipation depended upon the 
misplacement, and not upon the too great length of the 
colon. On the other hand, it may be asserted that there 
is really no such a thing as too great a length ; the colon 
is of proper length for the period of life, and required to 
be so for the proper absorption of the necessary quantity 
of nutritive material ; if it were shorter, the food would 

1 A. Jacobi, American Journal of Obstetrics, 1869. 
428 



HABITUAL CONSTIPATION DUE TO ATONY 429 

pass out too quickly and the infant would be starved. 
This is clearly shown by the fact that as the absorbent 
power of the individual portions of the intestinal canal 
become better developed, greater, the length of the colon 
diminishes. 

III. Too scant a secretion of intestinal mucus. This 
may depend upon insufficient development of the secret- 
ing apparatus of the intestinal mucous membrane. It may 
be due to the atonic condition of the whole intestine, or it 
may be the consequence of a catarrh, as already explained. 

IV. Congenital hypoplasia of the muscular coat may 
be a cause of constipation. See Part I. 

V. Constipation in consequence of dilatation and hyper- 
trophy of the colon. 

Hirschsprung reports the following cases : 

Case 65. A child born in the maternity hospital at Copen- 
hagen presented the peculiarity that, despite different laxatives 
administered, it had no stool. The same sluggishness of the 
intestines continued in the following months, and the most 
diverse remedies were employed. When a discharge was 
obtained, it was always of normal consistence and appearance. 
The child was otherwise well, and continued to develop nicely 
upon breast milk and Zwieback pap. For relief from this 
trouble it was brought to the policlinic. When I saw it here 
for the first time, the child had had but one small stool, a few 
hard scibala, in the past fourteen days. Nevertheless, the 
child did not appear to suffer any, and its appetite was always 
good. In the rectum an accumulation of scibala was felt which 
was removed by means of the finger and rectal injections. By 
the aid of different purgatives, the bowels were kept fairly open, 
and the condition continued good for a while ; when the appe- 
tite began to fail, the cheerfulness to disappear, and the skin 
took on a sickly look, the child was, at the request of the mother, 
received into the hospital. Age, eight months ; weight, 9000 



430 CONSTIPATION IN INFANTS AND CHILDREN 

grammes ; state of nutrition, satisfactory. During his whole 
stay in the hospital, our attention was entirely directed to the 
abdomen, especially to its evacuation. As a rule, the boy. had 
no fever ; vomited only exceptionally ; appetite very good ; in 
short he did not make the impression of being very sick. 
Never an evacuation spontaneously, and all our efforts were 
directed to effecting this. When a motion was obtained, the 
belly diminished in size, and the child evidently felt much 
relieved. The improvement was always of short duration. 
At the time I had not seen a similar case, and none was known 
to me from the literature. It appeared to me that a constric- 
tion of any part of the intestinal tract was out of question. 
The fact that a thick elastic tube more than an ell long could 
be introduced with greatest ease, and that on occasional explo- 
ration of the rectum it was generally found filled with faecal 
masses, spoke very clearly against any stenosis and for an 
atony of the intestinal tract. The treatment applied to rem- 
edy this condition proved futile, but by the daily administra- 
tion of a purgative combined with rectal injections the bowels 
were fairly well regulated. The abdomen was rarely distended 
to any extent, and the child left the hospital ; he had lost 
700 grammes in weight during his stay therein. He remained 
at home but a short time. The first eight days the child was 
very well and even had spontaneous discharges which were 
rather thin. Then the belly again became very much dis- 
tended, the discharges were frequent and thin, and he died on 
the same day that he was again brought to the hospital. His 
weight was 6900 grammes. 

Post-mortem Examination. — On opening the abdomen, sev- 
eral enormously distended loops of intestine present them- 
selves ; they are the sigmoid flexure, and the still more 
markedly dilated transverse colon. The other parts of the 
colon, with the exception of the rectum, are also dilated. 
No constriction anywhere. These parts are not alone dilated, 
but their walls throughout their whole extent are also very 
much thickened, especially the muscular layer. The mucous 
membrane of the more or less dilated parts is sown with ero- 



HABITUAL CONSTIPATION DUE TO ATONY 431 

sions and ulcerations which present marked differences as to 
size and depth. There are small superficial erosions and 
ulcerations barely the size of a pin's head which penetrate 
the whole depth of the mucous membrane. There are small 
superficial ones, and larger, formed apparently by the conjunc- 
tion of two or more ulcers, little bridges of mucous membrane 
traversing the ulcer being noted. At certain points the super- 
ficial surface of the intestine presents a peculiarly figured 
appearance. All the ulcerations and erosions are of round 
or oval form with smooth edges as if cut out with a punch. 
Here and there the borders are somewhat undermined. No- 
where intumescence of the follicles. On the serous surface not 
a trace of disease. Ligamenta and haustra coli not recogniz- 
able ; the appendices epiploicse strongly developed. The mes- 
entery of the sigmoid flexure is high, broad, and markedly 
thickened with rows of hypertrophied (to the size of a bean) 
bluish mesenteric glands. At the lower part of the ileum the 
plaques of Peyer stand out prominently. Otherwise, nothing 
abnormal in the body. 

Case 66. Waldemer H:, nurseling, seven months old, re- 
ceived into the hospital April 19, 1888. Suffered with consti- 
pation from birth, and only by the daily administration of 
purgatives could the bowels be kept open. Defecation was 
painless ; in fact, the child but rarely complained ; no eructa- 
tion, no vomiting ; developing very well. Occasionally the 
abdomen became very much distended, and lately it has gained 
in circumference. Since a month the distention has become so 
marked that the distressed mother brought the child to the 
hospital for relief. Punctures were made with a very fine 
trocar, and flatus evacuated ; the abdomen became somewhat 
smaller. By means of daily doses of castor oil and of rectal 
injections regularly administered, the bowels were kept open, 
and the boy left the hospital in a rather satisfactory condition. 
In a very short time, however, the abdomen again became dis- 
tended, despite the now numerous fa3cal discharges. He vom- 
ited but once ; he seemed to suffer considerable, cried much, 
and was therefore brought to the children's hospital. He was 



432 CONSTIPATION IN INFANTS AND CHILDREN 

an emaciated, delicate child, with an enormous belly, fifty 
centimetres in circumference. The loops of the intestine were 
clearly outlined on the abdominal parietes. Temperature in 
rectum 38.4°C. (= 100.5° F.). No excrement in the rectum, 
but a thin discharge follows the withdrawal of the finger. 
During his stay at the hospital, which was between four and 
five weeks, the diarrhoea, the distention of the abdomen which 
ranged from forty-one to fifty-six centimetres, and disappeared 
altogether toward the close of life, and the marked emaciation 
were the most prominent symptoms. The microscopic exami- 
nation of the rectal dejections showed finely granulated detri- 
tus, many large and small fat globules, granulated epithelium, 
and pus cells in great numbers. 

Post-mortem Examination: The colon very much dilated 
(somewhat less than in the previous case, sixteen to nineteen 
centimetres), but the hypertrophy was more pronounced. On 
the mucous membrane there are seen the same erosions and 
ulcerations, round and oval as if punched out with a punch, 
penetrating the whole depth of the intestinal wall. Besides 
these, there are found in this case single, large, and deep 
ulcerations, which penetrate as far down as to the serous cover- 
ing, and cause it to bulge out like a pocket without the least 
appearance on the spot of peritoneal inflammation. The cavity 
is empty, but has, undoubtedly, at one time held fluid con- 
tents. We find, indeed, spots where the process has remained 
at a preceding stage, whereby a better understanding of it is 
obtained. Not far from the ulcers just mentioned we find an 
abscess beneath the mucous membrane measuring two centi- 
metres in one and one centimetre in another direction. The 
incision shows us a whole meshwork of cavities in the sub- 
mucosa with purulent contents. Like cavities are found at 
other points ; not very many, however. That these abscesses 
may, in their progress, ulcerate through the mucous membrane, 
and also penetrate through the intestinal wall to the serous 
covering, is very apparent. 

Hirschsprung regards the ulcerations as secondary to the 
dilatation and hypertrophy. 1 As regards the development of 
1 See Part I., " Consequences of Constipation." 



HABITUAL CONSTIPATION DUE TO ATONY 



433 



the latter, he does not care to express an opinion ; only this he 
would say that, considering the fact that the constipation began 
almost with the first moment of life, it appears indisputable 
that the etiological factor must have been of intra-uterine ori- 
gin, either an anomaly of development or some morbid foetal 
process. 1 



i Jahrb. f. Kinderheilkunde, 1887. 



CHAPTER VI 

HABITUAL CONSTIPATION DUE TO ATONY (Continued) 

Habitual Constipation in Older Children 

Atony of the intestine in older children is due to the 
same causes, in so far as they pertain to this period of 
life, that give rise to it in the adult. A diet of too con- 
centrated food, a sameness in the dietary, too coarse food 
long continued, too little exercise, etc., all tend to retard 
the faecal evacuations. Two factors, however, merit spe- 
cial mention here, namely : 

I. Too Little Time taken for Defecation. — It will be 
found, and I have found it so rather frequently, that very 
lively, active, playful children become constipated for the 
reason that they do not take sufficient time to properly 
fulfil their duty to cloacinae. They will rush to the closet, 
and barely has the first portion of faecal matter been 
discharged when their mind is upon something else, they 
are up and away to play. Some may not even wait for 
this much ; they sit upon the closet for a minute or two 
with a mind upon a dozen other things, and the discharge 
not immediately following, they leave to attend to matters 
more interesting to them. Marked atony of the intestine 
follows, and constipation results. 

Parental inattention plays an important role in the 
constipation of children, especially of the category under 

434 



HABITUAL CONSTIPATION DUE TO ATONY 435 

consideration. Many mothers, perhaps most mothers, do 
not think it at all necessary to see to it that their children 
have regular motions. The fact that the child goes to 
the closet, or says that it does, suffices for them. When 
the physician makes inquiry upon this point, he will be 
told, " Oh, yes ! my child is regular, she goes to the closet 
every day." Of what value such testimony is, is very 
well illustrated by Case 4 of my article on " Intestinal 
Obstruction," * where the mother complained that her 
daughter was troubled with diarrhoea, whilst in fact the 
bowels were obstructed. When I receive the above an- 
swer, I always ask again, " How do you know that the 
bowels have moved ? Have^you gone to the closet to look, 
or have you inspected the vessel ? " Then they seem, 
amazed ; " No ! " I think too much stress cannot be laid 
upon this point, and when I am called upon to treat 
constipated children, I always strenuously insist upon it 
that the mother or some other trustworthy person shall 
make it her business to inspect the bowl or vessel after 
the child has used it, so that she may know by ocular 
demonstration whether the child has really had an evacu- 
ation, whether the faeces are normal in character and suf- 
ficient in quantity. 

II. Overstudy. — The crowding of the young mind 
with study exhausts the brain and nerves, weakens the 
muscles, and a general apathy follows. Moreover, chil- 
dren so crowded with mental tasks have no time for 
physical exercise ; their studies keep them in the house, 
and thus deprive them of that abundance of oxygen so 
necessary to their well-being. The appetite is poor, and 

1 American Journal of the Medical Sciences. 1886. 



436 CONSTIPATION IN INFANTS AND CHILDREN 

frequently capricious, and they eat very sparingly and 
very daintily ; the taste for the coarser aliments, so neces- 
sary to the proper functioning of the bowels, is lost. As 
a result of all this, constipation, very often of a most 
obsthiate character, ensues. 



CHAPTER VII 

SYMPTOMS AND DIAGNOSIS 

Symptoms. — With children, as with adults, the symp- 
tomatology of constipation has a very wide range. Whilst 
with some not the least disturbance of the general econ- 
omy is manifested, with others symptoms indicative of 
serious trouble may present. 

The symptoms, as already given in the preceding sec- 
tion, are diminution or loss of appetite ; coated tongue ; 
more or less foul breath ; discharge of offensive flatus ; 
headache. The child loses its cheerfulness, and becomes 
nervous ; it sleeps badly, restlessly ; wakes up several 
times in the night. Night terrors and grinding of teeth 
may be due to constipation. Colic, very severe colic, is 
very frequently one of the manifestations of a constipated 
state. Occasionally, but not very frequently, we have 
convulsions as one of the symptoms. They are most 
likely to occur, however, when some hard substance has 
been swallowed, and presses upon the rectal nerves or 
irritates the intestinal nerve filaments. 

Fever. — An elevation of temperature is sometimes the 
result of a constipation. Usually it is indicative of a 
sharp putrefactive process going on somewhere in the 
bowel. 

Faeces. — The faeces are changed in character and 

437 



438 CONSTIPATION IN INFANTS AND CHILDREN 

appearance. The great loss of water is one of the most- 
characteristic features. The faeces are of firm consist- 
ency, sometimes very hard, dry, and scybalous in form. 
Occasionally they may be clay-like and sticky. They 
vary in color from a dark green to a deep yellow, to an 
ashy gray in milk-fed infants; in children fed upon a 
mixed diet the color is the same as that of adults, — a 
lighter or darker brown according as more or less biliary 
matter is contained therein. 

When the stool is clay-like in character, it has usually 
a dark, tarry color. There is sometimes found adherent 
to the hard scybala, bloody mucus or pure blood derived 
from a superficial erosion of the mucous membrane. 

The scybala becoming firmly adherent to the mucous mem- 
brane, the separation therefrom, by the powerful peristalsis 
excited by one means or another, leaves a superficial erosion 
of said mucous membrane. 

Defecation. — The act of defecation is occasionally more 
or less painful, and generally requires much effort. The 
face of the child during the act becomes red, turgid, even 
reddish-blue; it is covered with perspiration. Great down- 
ward pressure is made, and finally one or two small, hard 
lumps are discharged, or, perhaps, nothing more than a 
little flatus. 

Diagnosis. — The diagnosis of retardation of faecal dis- 
charges is one the most readily made. It is apparent. 
What is more difficult is to differentiate the habitual con- 
stipation due to an atonic state of the intestinal tract 
from constipation, the result of insufficient food, and from 
chronic constipation dependent upon morbid processes in 
the abdomen or elsewhere. As regards the first a care- 



SYMPTOMS AND DIAGNOSIS 439 

ful inquiry into the history and life of the infant or child, 
the quantity and character of the food taken by it, — and 
as to the latter a careful examination upon the lines laid 
down in Part I., will soon disclose the truth to us. 

In all constipated infants and children who are fretful, 
given to crying much, the anus should always be examined 
for a possible fissure or excoriation thereabout. 



CHAPTER VIII 

TREATMENT OF CONSTIPATION DUE TO ATONY OF THE 
INTESTINE {Infants) 

I. When the constipation of the infant is dependent 
upon the constipated habit of the mother, we will en= 
deavor to remedy this. 

In the earliest part of the post-partum period, by the 
regular administration to the mother of some mild but 
efficient cathartic, — magnesia, Rochelle salts, the tonic 
laxative, 1 or some one of the laxative mineral waters, as 
Hunyadi Janos, Rakoczy, Villacabras, or Hathorne (Sara- 
toga), all in appropriate doses, just sufficient to keep the 
bowels soluble. The good effects of this treatment will 
soon manifest themselves in the greater solubility of the 
infant's bowels. 

It is, of course, absolutely necessary to avoid such 
remedies as have a subsequent constipating effect, as 
castor oil or rhubarb, and such as have a tendency to 
gripe, as otherwise, in the case of the latter, the child will 
be severely troubled with colic. 

At a later period, when the mother has recovered her 
former vigor and is able to be up and about, we will 
treat her constipation upon the principles and by the 
methods laid down in Part I. 

1 See " Formulary," Part I. 
440 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 441 

Generally, with the relief of the mother the constipa- 
tion of the infant will be cured. 

II. Where the constipation is dependent upon a faulty 
composition of the mother's milk. 

(a) Too great a Percentage of Casein. — Whether we 
are to understand by this an amount beyond what has 
been found to be the maximum, 1 is not explained. In 
the sense of an abnormally high percentage of the nitrog- 
enous element, I have not myself seen a case or read one 
reported. 

When we are confronted by such a condition, or where 
the percentage of casein, though within normal limits, is 
nevertheless too large for the digestive capacity of the 
child, we must attempt to correct this by dietary meas- 
ures. Theoretically, we should be able to accomplish 
something, and experimental observation seems to verify 
this to some extent, 2 by putting the mother upon a diet 
composed mainly of carbohydrates and fats, with but a 
minimum of the nitrogenous element, and that only in 
the form of lean meat. 

In addition, we may avail ourselves of the benefits to 
be derived from a course of mineral waters. The alkaline 
waters, as Vichy or Bilin, or the milder muriatic waters 
(alkaline-muriatic), as Selters, Ems, Luhatschowitz, or a 
bitter water, as Kissingen or Friedrichshall in minimal 
quantity freely diluted, may be prescribed. 3 

Where with all these we do not succeed, and the diges- 
tive disturbances are prolonged and tend to become seri- 

1 The casein in mother's milk ranges from 0.18 to 1.90. 

2 Foster, Physiology. See references there. 

3 Balneo-Therapie, Handbuch der Allgemeine Therapie (Ziemssen) ; 
"Mineral Waters," Dictionary of Medicine, Q.uain. 



442 COXSTIPATIOX IX IXFAXTS AXD CHILDREN 

ous, the question of a wet nurse or a resort to artificial 
feeding must be considered. 

(b) Too Small Percentage of Sugar. — Here, also, we 
should, at the very first, endeavor to remedy the defect 
by proper dietary regulations. Such articles of food as 
are rich in starch — potatoes, rice, tapioca, arrowroot, white 
bread — should constitute a large part of the diet, with the 
nitrogenous element and the fat in just proportion. In 
addition, dishes prepared with an abundance of sugar and 
suorar itself should be taken freely. 1 

Jacobi seeks to remedy the difficulty by administering 
a quantity of sugar to the infant to make up the defi- 
ciency. He directs that the child be given from thirty to 
sixty grains (2.0-4.0) of loaf-sugar dissolved in tepid 
water before each nursing. 2 If, as claimed, lactose or milk 
sugar possesses laxative properties, it is the better form of 
sugar to administer. Maltose or malt sugar can also be 
employed for the purpose. 

This latter method is very well as a temporary makeshift 
until the mother's milk can be brought up to the normal stand- 
ard, and for the exceptional cases where this cannot be accom- 
plished. 

III. In infants fed with cow's milk the constipation is 
due to the greater amount of casein that this contains 
and its more difficult digestion. To remedy this, the milk 
must be properly diluted so as to reduce the percentage 
of casein, and make it conform to that found in breast 
milk. Ordinarily it may be said that in the early period 
of infantile life the dilution should be one part milk and 

1 Foster, Physiology, " Sugar." 

2 American Journal of Obstetrics, 1869, loc. cit. 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 443 

three to four parts water ; after the third month, one part 
milk and two to three parts water ; after the fifth month, 
one part milk and one to two parts water; 1 after the eighth 
month, the milk can be given undiluted. 

Under the circumstances here considered, oatmeal water, 
which is perhaps possessed of some laxative properties, 
will be an excellent diluent. Moreover, it prevents the 
too firm and too close clotting natural to the casein of 
cow's milk. 

As the dilution will also reduce the fat and sugar con- 
stituents below the normal limit as fixed by breast milk, 
we will have to make good this loss by the addition of 
cream and sugar (loaf or milk sugar). For further details 
on this subject see the Cyclopaedia of Diseases of Children, 
American Text-book of Diseases of Children, Diseases of 
Children, by J. Lewis Smith, and that very excellent 
little book by Dr. Louis Starr, the Hygiene of the 
Nursery. 

Pap-fed children must be brought back to a milk diet. 
Condensed milk prepared with oatmeal water will be the 
most suitable food at the outset. 

IV. Improper Feeding. — As already stated, so far as 
my own experience goes I am decidedly of the opinion 
that the greater part of the difficulties encountered in 
feeding with cow's milk (and not infrequently the diges- 
tive troubles of breast-fed infants) are due to improper 
feeding; namely, they are fed too often or too much, or 
both. 

1 The more or less of the water depends upon the digestive capacity of 
the child. See the tables of dilution of Monti, Uft'elmann, and of the 
Verein der Medicinal Beamten, etc., in Wie behutet maun Leben u. 
Gesundheit der Kinder, by Ernest Briicke, Vienna, 1892. 



f, . 



444 CONSTIPATION IN INFANTS AND CHILDREN 

This point, upon which too much stress cannot be laid, 
must be regulated in accordance with the well-formulated 
rules that have been established, and that a large and 
long experience has demonstrated to be correct. 

Breast-feeding. 

One breast only is given at a nursing. 

For the first week after the establishment of the flow, 
the child can be given the breast every hour and a half 
from 5 a.m. to 11 p.m. When the flow is abundant, the 
breast having a very abundant supply, every two hours 
will suffice. 

At this early period one nursing in the course of the 
night (about 2 a.m.) may be allowed. 

After the first week to the end of the tenth week, every 
two hours from 5 a.m. to 11 p.m. 

No feeding during the night after the first week. 

From the eleventh week to the end of the fourth month, 
every two and a half hours from 5 a.m. to 11 p.m. 

From the fourth month to the end of the tenth month, 
every three hours from 5 a.m. to 11 p.m. 

The intervals of time between the feedings, as above 
given, are adapted for the great majority of infants; here 
and there a child with strong digestive capacity may re- 
quire either a shorter interval or a larger quantity at each 
feeding. The former is the preferable to do. 

Where mixed feeding is resorted to, i.e. breast and 
bottle (and it is always desirable to retain the breast in 
function as much and as long as possible, especially in 
the early period of the infant's life, for the benefit of 
both mother and child), the breast and bottle must 
never be given together at one nursing ; they should be 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 445 



BOTTLE FEEDING 



Age 



Interval 



Quantity at Each 
Feeding 



During the first week, 
and early part of 
second. 



From the middle of the 
second to the sixth 
week. 

From the sixth week to 
the end of second 
month. 

At the third month. 



At the fourth month. 

At the fifth month. 

At the sixth month. 

At the seventh month. 
At the eighth month. 



Every two hours from 

5 A.M. to 11 P.M. 

Occasionally once or 
twice during the 
night. 

Every two hours from 
5 a.m. to 11 p.m. No 

night feeding. 

Every two hours from 
5 a.m. to 11 P.M. 



Every two and a half 
hours. {Same hours.) 



Every two and a half 
hours. (Same hours.) 

Every three hours. 
(Same hours.) 

Every three hours from 
7 a.m. to 10 P.M. 

Every three hours. 

Every three and a half 
hours. 



One (1) ounce. 



One and a half (1|) 
ounces. 



Two (2) ounces. 



Two and a half (2i) 
ounces in the first 
part, three (3) ounces 
in the latter part of 
the month. 

Four (4) ounces. 



Five (5) ounces. 

Six (6) ounces. 

Seven (7) ounces. 
Eight (8) ounces. 



446 CONSTIPATION IN INFANTS AND CHILDREN 

used separately; at one nursing the breast, at another, 
the bottle. 

The physician can make himself certain that the regi- 
men he has prescribed gives a sufficient supply of food by 
occasional and careful weighing of the infant, and noting 
thus whether it is gaining in due proportion or not. 

Children that are thus properly fed are, as a rule 
(breast-fed infants always), free from that irritability 
which causes the long and harassing crying spells which 
are always more or less present in overfed children, and 
which with them are always an expression of a dyspeptic 
condition, and not infrequently of a beginning catarrh of 
the stomach. They will also be free from the frequent 
attacks of colic to which overfed children are so liable. 

With older infants, one and one-half to three years, the 
dietary errors that demand our attention vary with the 
station in life of the parents. Among the middle and 
poorer classes, the children, already at an early age, are 
fed with gross coarse food such as is furnished for the 
adults ; and dyspepsias, even ectasias of the stomach, and 
constipations are frequent results. Among the wealthy 
class the other extreme is the rule, — too bland a diet is 
provided. These faults of alimentation must be corrected, 
and a proper dietary for the children prescribed. 

For additional information upon the feeding of infants, 
see Diseases of Children, by J. Lewis Smith, the Ameri- 
can Text-book of Diseases of Children, and the Hygiene 
of the Nursery. 

I do not think it necessary, ordinarily, to prescribe the 
free administration of water to very young infants except 
in the hot months when the system is continually drained 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 447 

thereof by the very abundant perspiration. There is suffi- 
cient water in their food. The dryness of the faeces is not 
due to an insufficiency in the quantity of fluid, but rather 
to the long retardation of the matters in the bowel and 
their consequent inspissation. 

V . From Drugs. — It will certainly be admitted that 
to administer drugs or alcoholic liquors to an infant to 
stupefy it, so that mother or nurse may enjoy undisturbed 
their selfish pleasures, is criminal. No physician who has 
the welfare of his little patient at heart should hesi- 
tate one moment to denounce such an abominable prac- 
tice. What seeds for future evil are thus laid ! 

But even for those frequent infantile colics (due to flatu- 
lence, from indigestion, or to the swallowing of much air in the 
act of nursing) there is no necessity for a resort to opiates or 
brandies or whiskies. We have other agents equally, and, 
indeed, much more effective and withal harmless. These are : 

1. First and foremost milk of assafoetida. Made as already 
described here, there is nothing that will so quickly relieve the 
colicky pains of the infant. Infants take it readily, especially 
if sweetened by the addition of a little sugar to each dose as 
administered. One-half to one teaspoonful can be given at a 
time, and repeated every fifteen minutes until relief is afforded. 
Usually not more than one or two doses will be required to 
accomplish this purpose. With a bottle of this preparation at 
hand, infantile colic loses its terrors, and heartless mothers and 
worthless nurses are deprived of all grounds for their nefarious 
drugging. 

2. Star anise (Illicium anisatum, Fructus illicii) is also very 
good, though inferior to assafoetida. It can be used in the form 
of a tea ; three to five pieces of star anise are broken up, and 
one-third of a cupful of hot water poured over them and al- 
lowed to steep for about ten minutes. When cooled down to 
the right degree of warmth, sufficient sugar is added to make 



448 COXSTIPATIOX IN INFANTS AND CHILDREN 

the tea palatable, and three to five, or more, teaspoonfuls 
thereof are given at a time. 

Essence of anise (Essentia anisi): ten to twenty drops in 
one-third of a teacupful of warm water sufficiently sweetened, 
and administered as directed above. 

3. Caraway QCarum, Kummel) is also serviceable. A small 
quantity of the seeds (one-third of a teaspoonful) is bruised 
upon powdered sugar and rubbed up with it ; four or five table- 
spoonfuls of hot water are poured over it ; a tea is thus made, 
and administered as directed above. 

Special Measures 

Besides these more general measures, we will make use 
of others more especially addressed to the bowels and to 
their evacuation. 

I. Medicines. 

A. For the New-horn. — For the very earliest period of 
infantile life, the first month, we can avail ourselves of 
the laxative action of 

Manna. — It may be prepared after various formulae 
or simply as a tea, — a solution. A good-sized lump of 
manna (or two or three smaller lumps) is dissolved in 
four or five tablespoonfuls of water, and then administered 
freely to the infant. As the age progresses, from two 
weeks on, larger doses are required. 

It is generally effective. 

Syrup of Rhubarb. — One-third to one-half teaspoonful 
every two or three hours. This has the disadvantage, how- 
ever, of a rather constipating after effect. 

Syrup of Rhubarb and Manna. 

B. For Older Infants. 

Magnesia (Carbonate or Calcined, usta) grs. v— 3 ss. It 
can be given in sweetened water (sweetened oatmeal water). 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 449 

Rhubarb, syrup, wine or powder. The latter form usu- 
ally in combination with magnesia. 1 

J. Lewis Smith 2 prescribes the following formula for con- 
tinued use upon the supposition that an insufficiency of fat and 
sugar is the cause of the constipation. 

^ Ole. Morrhuse 5 iv 

Aq. Calcis 

Syrup. Calcis Lactophosphat. aa !> ii 
M. ft. Mixt. Sig. Shake bottle. One-half to three-fourths 
teaspoonful, three times daily. 

This is an excellent prescription for the constipation of 
rhachitic children. 

II. The clyster can be used from the earliest period of 
infantile life. Even with the new-born when there is 
retention of meconium a warm rectal injection may be 
given to provoke its discharge. 

Instruments. — A glass syringe should never be used. 
It is a dangerous instrument ; a little unskilfulness on 
the part of the mother or nurse, and a laceration or ero- 
sion of the delicate mucous membrane is produced. A 
sudden movement on the part of the child, and the instru- 
ment may be broken, and injury result. With all these 
disadvantages there is but little force to it, insufficient 
even for the infant. For the very young infant the hard 
rubber syringe of three ounces' capacity, with a fairly 
long and smooth nozzle, is the best instrument. It can 
be used for the injections of water or the clysma of oil 
already described. For older infants, from the third 
month on, I prefer to use the fountain syringe. 

1 See " Formulary," Part II. 2 Diseases of Children. 



450 CONSTIPATION IN INFANTS AND CHILDREN 

How to administer the Enema. — When the small, hard 
rubber syringe is used, a sufficient quantity of water hav- 
ing been drawn in, the tip is well anointed with vaseline 
(or oil), and the child, lying in its crib or placed upon a 
couch or on the table, is laid on its left side or on the 
back with the legs held well drawn up ; the buttocks 
are separated, and the point of the syringe, directed some- 
what to the left, gently and gradually insinuated past the 
sphincter into the rectum. The piston-rod (one with a 
ring at its further extremity is best) is then pushed for- 
ward, not too fast, and the fluid thrown in. 

It may also be given with the child in this position : 

When the fountain syringe is used, the mother may 
seat herself in a low chair with the infant placed upon 
her knees, belly downward, the thighs of the infant just 
coining over the mother's knee and hanging down. The 
reservoir of the syringe (the fountain) is placed at a height 
of about one foot (to a foot and a half) above the infant's 
buttocks. The rectal point, well anointed with vaseline 
(or oil), is introduced into the rectum, and the water 
allowed to flow. Given in this way, the injection is 
always effective, and never has harm resulted therefrom. 

Where the mother is alone, without a nurse or assist- 
ant, this last position is the better for the easy and rapid 
accomplishment of the purpose. 

Quantity. — The amount of fluid to be used for an 
injection varies with the age of the infant ; for the new- 
born, three-fourths to one ounce (one and one-half to two 
tablespoonfuls) ; from one month to six weeks, one and 
one-half to three ounces (three to four tablespoonfuls) ; 
at three months, two and one-half ounces (five tablespoon- 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 451 

fuls) ; for a child of one year, five to seven ounces (some- 
what according to the size of the child). 

Fluids. — Water is, of course, the fluid most commonly 
used. Some medicate this, to make it more stimulating, 
with salt, soap, castor oil, or glycerine. I prefer to use 
plain water, and have always found that, injected with the 
fountain syringe, equally as good an effect was obtained 
with the unmedicated as with the medicated water, with 
the further advantage of the minus of the local irritation 
which the various agents employed tend to excite. 

The only addition to the water that I occasionally advise 
is that of lac assaf cetidse, 3 ii- 5 ss (two teaspoonf uls to one 
tablespoonful), in cases where there is much flatulence. 

The water should be a little more than lukewarm, — 
93° F. to 95° F. This also contributes to its effectiveness. 

When (in older infants) the injections are to be used 
for any length of time, the temperature may be gradually 
reduced (two or three degrees at a time) until water at a 
temperature of 78° F. to 75° F. can be injected without 
discomfort. 

Oil. — The technique and details of the oil clyster have 
already been given. Here it need only be said that the 
oil injection is equally applicable to the young infant, 
especially where there is a tendency to marked inspissa- 
tion and hardening of the fasces. One to four teaspoon- 
fuls, according to the age, of warmed olive oil * can be 
injected into the rectum, and if necessary followed in four 
or six hours by an injection of water. 

Glycerine. — The glycerine injection, i.e. the injection 
of a quantity of glycerine into the rectum, whether pure 

1 See page 354. 



452 CONSTIPATION IN INFANTS AND CHILDREN 

or diluted somewhat with water, should not, I think, be 
used in infants. It is far too irritating to the parts, causes 
considerable straining, and a prolapse of the rectum, — a 
not uncommon occurrence in young children, — or even a 
proctitis may result therefrom. 

III. Massage. — As with adults so with infants, mas- 
sage is the most potent remedy for this form of constipa- 
tion. No matter what the cause that may have primarily 
produced it, massage will, in almost every instance, prove 
effective in overcoming the atony, and this frequently in 
a very short time. This is the consensus of experienced 
podiatrists, 1 which my own personal observation confirms. 

The following case very well illustrates its effectiveness 
and the rapidity of the action : 

Case 67. Bab} r G., cet fourteen months; breast and bottle 
fed ; stout, healthy-looking boy. In the summer of 1893 he 
suffered severely with intestinal catarrh, which lasted a long 
time and reduced him very much. His grandmother brought 
him to me for relief from constipation, which is said to have 
supervened shortly after the cessation of the diarrliceal affec- 
tion, and with which he has been troubled for over five months 
now, and which is daily growing worse. It requires now larger 
doses and stronger to give him a free evacuation. The symp- 
toms are very characteristic ; when at stool he strains until he 
is almost purple in the face ; he cries out, and sometimes utters 
piercing shrieks. The evacuation, unless the result of a pur- 
gative, consists of a few scybala of stony hardness, usually cov- 
ered with mucus, which very frequently is streaked or tinged 
with blood. When done, he sinks back exhausted, and it is an 
hour or more before he has recovered himself. 

The time of stool for the infant is an hour of dread for the 
parents and grandparents. 

A physical examination revealed nothing especial. 

1 A. Jacobi, J. Lewis Smith, Troitzky, Baginsky, Henoch, Karnitzky. 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 453 

Diagnosis. — Constipation consequent upon intestinal catarrh. 

Treatment. — The child is to have oatmeal porridge with 
milk in the morning, and twice a day a tablespoonful of mo- 
lasses with crumb of bread. 

The bowels are to be washed out every third day with a large 
injection, — a teacupf ul and a half of water at a temperature 
of 90° F. at the outset, with a gradual reduction of the same in 
the course of a few weeks to 80° F. 

Being a very intelligent woman, I instructed the grandmother 
in the technique of the massage, and directed her to apply the 
same every day for the first two weeks, and then every other day. 

In three weeks there was a marked improvement ; at the end 
of the second month the child was reported well. I have seen 
him since ; there has been no relapse ; his bowels continue to 
act with regularity and ease. 

It is of inestimable value in those dyspeptic conditions 
dependent rather upon insufficient development or ineffi- 
cient action of the digestive organs than upon an indi- 
gestibility per se of the aliment. Here it will not alone 
strengthen the intestinal muscles and invigorate the peri- 
stalsis, thus quickening the onward movement of the in- 
testinal contents, but it will also, by stimulating the 
circulation both in the blood-vessels and the lymphatics, 
forward the development of, or render more energetic, the 
special digestive apparatus of the intestinal tract, and 
fortify both the pancreas and the liver in the performance 
of their physiological function. 

It is the most important measure in the treatment of 
atony due to a dilatation of the bowel or a section thereof, 
and combined with constitutional remedies it is of the 
greatest service in the treatment of constipation depen- 
dent upon a rachitic dyscrasia. 

IV. A measure of secondary importance, but of some 



454 CONSTIPATION IN INFANTS AND CHILDREN 

utility in very obstinate cases, is the application of cold to 
the abdomen. The effects of cold water upon the abdomi- 
nal muscles and the organs beneath them have been 
already set forth. In young infants (three months) the 
only method of application that I deem advisable is this : 
I direct that in the course of the morning when the child 
is having its regular bath or wash that its belly be rubbed 
with a cloth dipped in cold water, temperature 80° F. to 
75° F., and that this be quickly followed by frictions with 
a well-warmed towel. 

For older infants (ten months) we may use water at a 
much lower temperature, 75° F. to 65° F., or if it be the 
summer months, we may advise the cold bath, accustoming 
the child gradually thereto after the manner described. 

In very obstinate cases we may resort to the cold douche 
to the abdomen. In infants and young children it should 
never be given through the showering apparatus con- 
nected with the water pipes, but by means of a sprinkling 
can or the fountain syringe, a nozzle as described on 
page 279 being fitted thereto. 

Y . Regularity of Habit. — It is so general a custom that 
it need hardly be mentioned. Even very young children, 
from six to seven months, and exceptionally strong ones 
already after the fourth month, can be accustomed to use 
the vessel (placed beneath an appropriate chair on which 
pillows are arranged, so that the child is well supported 
and perfectly comfortable thereon). By placing them on 
the vessel at a certain fixed time or times 1 of the day, 
a regularity of habit is acquired by the child which is cer- 
tainly of advantage in the treatment of the constipation. 

1 After the fourth month up to the second year many children have two 
stools per day; many others have but one. 



CHAPTER IX 

TREATMENT OF CONSTIPATION DUE TO ATONY OF THE 
INTESTINE {Continued) 

Older Children 

The treatment of constipation in older children does 
not differ in any respect from what has hitherto been 
said. The causes that lead to the retardation of the 
faecal discharges are very much the same as we find in 
adults, and their correction must necessarily be after the 
same methods. 

As regards the two factors that have been specially 
mentioned here : 

I. When the child, too playful, does not take sufficient 
time at stool, the mother or nurse must accompany it to 
the closet, and see to it that it remain on the receptacle a 
sufficient length of time. Furthermore, they must not 
divert the child's attention by gossip on extraneous mat- 
ters, but rather fix its mind upon the duty before it by 
reverting to it in conversation, and impressing upon the 
child the necessity for a full and free evacuation. B} T 
such measures, even though at the outset no larger dis- 
charges may follow, the habit of taking sufficient time 
for this important physiological function will be formed. 
and its good effects will manifest themselves at an early 
day. 

455 



456 CONSTIPATION IX INFANTS AND CHILDREN 

II. When the child is overburdened with studies, it must 
be released from them. The regulation of this will de- 
pend greatly upon the age, the physical development, and 
the intellectual capacity of the child. For bright, intel- 
lectual children it will be frequently found that studies 
that are a mere matter of memorizing, as geography, 
spelling, are the hardest tasks, whilst with duller children, 
it is those that excite and stimulate the thinking power. 
With some children, bright otherwise, arithmetic and 
mathematics will be very hard and exhausting studies, 
whilst with others it will be just the reverse. Sometimes 
it may be necessary to keep the child out of school alto- 
gether. However it may be for exceptional cases, gener- 
ally it will suffice if we insist upon these two points : 

1. That the child shall have ample time to be out and 
exercise in the open air. 

2. That it shall not study after the evening meal. 

The special measures to be employed are the same as 
have been described. 

Younger children up to the seventh or ninth year (ac- 
cording to the physical development) will be treated more 
after the fashion of infants. We will treat them with 
injections and with massage, and this latter will be that 
described in the second part, plus a little more force added 
in our manipulations than would be necessary for infants. 

For older children the treatment will be the same as for 
adults. The massage will be as described in Part I., 
minus a little of the force put into the execution of the 
manipulations in grown persons. 

As regards the measures of hydrotherapy, the injections 
or clysters have already been mentioned as applicable at 



CONSTIPATION DUE TO ATONY OF THE INTESTINE 457 

all ages, from the very earliest period of childhood 
(another form of clyster (oil) has also been described). In 
the summer, the hot months, the cold bath is applicable 
even in infants ; * in the cold months children do not bear 
the cold bath well ; very young children not at all ; and 
with older ones much depends upon their physique and 
their nutrition, and not a little upon the heating facilities 
of the dwelling. The cold douche to the belly may be 
used even with young children, 2 and even in the cold 
months. The long-continued wet applications, as the 
cold, wet compress, 3 are not well borne by young children, 
and should not be prescribed for them ; for older children, 
from six years on, they are decidedly advantageous. 4 

Electricity. — Children, and more particularly young 
children, are not very tolerant of its application. In fact, 
we are so generally successful with the other measures 
named that it will rarely be required. When its employ- 
ment becomes necessary, however, the modes of applica- 
tion are the same as for adults, as have been described in 
Part I. 

1 See " Summer Complaint," etc., New York Medical Journal, 1892, by 
H. Illoway, M.D. 

2 As described for infants. 

3 See section on Hydrotherapy. 

4 J. Lewis Smith, Diseases of Children. 



CHAPTER X 

ANATOMICAL 

We find very frequently reference made to the ana- 
tomical differences between the abdominal organs of the 
infant and those of the adult, and from the character of 
some of these statements one might be led to infer that 
these differences existed throughout the whole period of 
infantile life. For a clearer understanding of this impor- 
tant point, it has been gone into in some detail here, more 
especially as it is of some importance for the practice of 
infantile massage. 

Stomach. — In 1837 Schultze 1 wrote: "The stomach 
in its earliest developmental stages runs through the 
cylindrical form of stomach of fishes and amphibia ; for 
we see the stomach, in the early embryonic period, as a 
slight distention of the oesophagus, of cylindrical form, 
hanging straight down in the abdominal cavity, so that 
the cardia is directed upward and the pylorus downward. 
The transverse position of the stomach is of much later 
date, established only with the full development of the 
curvatures. The stomach of the child is rather of the 
spherical form drawn out lengthwise, and becomes narrower 
at both ends, — above at the cardia, below at the pylorus. 

1 Schultze, "Ueber Art u. Verschiedenheit des Erbrechens," etc., Analecten 
ueber Kinderheilkunde, 1837, Bd. II. Quoted by Henschel, "Ueber Magen- 
erweiterung im S'auglingsalter," Archiv fur Kinderheilkunde, 1891, Bd. XIII. 

458 



ANATOMICAL 



459 



The oesophagus is inserted into the fundus proper, and is 
at a great distance from the pylorus ; the small curvature 
is thus rather long drawn out. The greater curvature is 
less developed and almost parallel with the lesser ; in 
one word, the stomach is very much like that of the 



carnivora. 



According to the more exact description of Fleisch- 
mann, 1 the stomach of the young infant occupies the left 
hypochondrium exclusively, and only when very much 
dilated does it extend into the left epigastrium. The 
small curvature lies on the left side of the vertebral 
column, and parallel with it, and only at its lowest part 
does it assume a horizontal direction, so that the pylorus 
lies about the middle line ; the greater curvature passes 
through the centre of a vertical line drawn from the 
xiphoid cartilage to the umbilicus. When the stomach 
is full, the fundus, extending beyond the cardia, forms 
the highest, and the pylorus the lowest point ; but only 
when its walls are enormously distended does the pylorus 
extend beyond the median line to the right. 

A careful comparison of this with the description, and 
more especially with the chart of the adult stomach as 
given by Luschka, 2 will disclose the fact that the infantile 
stomach differs but little in position from that of the adult, 
and that what little difference there is, is more a matter 
of size. 

The correctness of this is affirmed also by Symington, 3 
who says : " My own observations are in favor of the view 



1 Fleischmann, Klinik der Pediatrik, 1875. Henschel, ibid. 

2 Luschka, Die Bauchorgane des Menschen. 

8 Symington, Topographical Anatomy of the Child. 



460 CONSTIPATION IN INFANTS AND CHILDREN 

that the shape and situation of the stomach in children are 
practically the same as in the adult. In newly born 
infants the stomach is either empty or it contains only 
a small quantity of mucus. In them the long axis of the 
main part of the stomach is directed downward and for- 
ward ; there is a small fundus which projects upward and 
backward, and the pylorus lies in or very close to the 
mesial plane." 

It is therefore very evident that the general statement 
as to the marked differences as to position between the 
infantile and the adult stomach is only true for a very 
short period, three or four days, not longer; for Sym- 
ington 1 refers to the stomach of an infant four days 
old occupying the same position as that of the child one 
year old. 

The most marked difference between the infantile and 
the adult stomach (so far as external configuration and 
position are concerned) is the great extent to which the 
former is covered on its anterior surface by the liver 
(left lobe), as shown in our illustrations, frontispieces 
I. and II. 2 

Liver. — The liver is of enormous size, and covers three- 
fourths of the abdominal cavity, the left lobe extending 
far over to the costal cartilages of the left lower ribs. 3 It 
decreases in volume as the child grows older, and at the 
close of infantile life and the beginning of childhood, 
about the fourth year, according to Beneke, 4 it assumes 

1 Loc. cit. 

2 See also McClellan, " Anatomy of Children " (in Cyclopaedia of the Dis- 
eases of Children, Keating). 

3 See frontispieces I. and II. 

4 Deutsche medizinische Wochenschrift, 1880. 



ANATOMICAL 461 

the position it is found in in the adult. The decrease is 
most rapid in the earlier months. 

It varies so much in size within the limits of health 
that its boundaries at the various periods of life cannot 
be given with any exactness ; moreover, the extent to 
which it may project beyond the costal arch (not infre- 
quently one to two centimetres) depends considerably upon 
the height of the diaphragm and the shape of the thorax. 1 

Bowels. — In the new-born, owing to the immense size 
of the liver, the whole mass of the small intestines, the 
descending colon, and the sigmoid flexure partly, lie in the 
left half of the abdominal cavity. The small intestines 
making many convolutions, the left colic flexure and the 
descending colon descend from the spleen to the upper 
border of the pelvis. The remaining abdominal space on 
the right side is occupied by the caecum and its appendix 2 
and what there is of the ascending colon. 

The sigmoid flexure and the rectum are rather feebly 
developed in the new-born, and until the second or third 
month have no fixed position, though they are most fre- 
quently found to the right. Boucart, in one hundred and 
fifty autopsies, found the sigmoid flexure eleven times to 
the left, six times in the true pelvis, and thirty-three 
times placed transversely from left to right. 8 

The ascending colon and the transverse colon are also 
but feebly developed in the new-born, short, and do not 
differ in calibre from the rest of the large bowel. 

1 Symington, loc. cit. McClellan, loc. cit. 

2 Karnitzky, " Bauchmassage an Kindern," Archiv f. KinderheWkunde, 
1890-1891, Bd. XII. 

3 Massini Viginro, Fisiologia della infanzia e fanciulezza, Genova. 1886, 
and Karnitzky, loc. cit. 



462 



CONSTIPATION IX IXFAXTS AXD CHILDREN 



Their development is rather slow till in the third 
month, when they begin to make rapid strides forward. 




From the Cyclopaedia of the Diseases of Children. (Keating.) Vol. I. 



Photograph of a recent dissection in which the viscera were held in position by 
transfixion with pins: from a new-born child. — 5. Central tendon of diaphragm; 
6, round ligament of liver; 7, right lobe of liver: 8, right kidney: 15. left lobe of 
liver : 16, stomach : 17, sigmoid flexure of colon. The small intestines are removed. 



ANATOMICAL 



463 



The caecum in the new-born lies very high, almost 
beneath the ribs. 1 




Diagram of the Figure. 
1 Karnitzky, loc. cit. McClellan, loc. cit. 



CHAPTER XI 

MASSAGE 

Preliminary Considerations 

Some podiatrists advise the practice of massage even 
in the youngest infant, and Karnitzky 1 relates the case 
of his nephew, whom he thus treated a short time after 
his birth. I myself do not favor or advise its application 
until the child is at least six weeks old, and for these 
reasons : 

(a) Abdominal massage for constipation is addressed 
mainly to the muscles of the large bowel, and the main 
portions of this organ are, as we have seen, but feebly 
developed at an earlier age ; not much benefit can there- 
fore be derived therefrom. 

(6) The very young infant is exceedingly sensitive to 
the touch, cries quickly, and at the slightest pressure 
made its abdominal walls are drawn tense, and all our 
efforts are in vain. 

(c) The course of treatment here advised for these very 
young sprouts of humanity gives results so satisfactory, is 
so simple, and so readily carried out, that resort to more 
forcible measures is unnecessary. 

The only exceptions I make to this rule are the cases 
of hand-fed infants, where marked dyspeptic phenomena 

1 Loc. cit. 
464 



MASSAGE 



465 



attend the constipation, where the latter seems to be 
dependent upon the former, and where the question of 
insufficient development or inefficient action of the special 
digestive apparatus arises. Here the massage is addressed 
chiefly to the small intestines after the method described 
further on. 

1. In young infants massage is best made whilst the 
child is either nursing the breast or taking the bottle ; in 
this way we may readily obviate its crying, and thereby 
the drawing tense of the abdominal walls. In older 
infants (after six months) this precaution is not necessary. 

2. All bands around the abdomen and thorax must be 
loosened. 

3. With infants who are easily frightened, uncovering 
of the abdomen alone may bring on a crying spell that 
will make massage impossible. Then again, the abdomen 
being always kept well covered, a sudden exposure of it, 
especially if it be a cool day, may cause a rapid and strong 
reaction to the manipulations of the masseur. 

The whole belly need not be exposed at the time of 
treatment ; in fact, it need not be uncovered at all if the 
masseur is expert in the execution of the manoeuvres, and 
familiar, without sight, with the locality to which the 
treatment is applied. 

4. The amount of the pressure made by the hand will 
depend upon the degree of tension of the abdominal 
parietes ; it can be greater when these are more relaxed 
and less so when they are more tense. It is best to pro- 
ceed gradually from the very slight and superficial to the 
greater and more profound pressure. 

5. A correct measure of the innocuousness of our 



466 CONSTIPATION IN INFANTS AND CHILDREN 

manipulations are the abdominal walls ; they will remain 
relaxed and loose if the massage be harmless, as it should 
be, but will be drawn tense at once if the least pain is 
inflicted. 

To attempt to overcome the reaction of the infant to 
the application, despite the tenseness of the ahdominal 
walls, by the exercise of still greater and more penetrating 
pressure, would be to commit a grave and serious error. 

When despite our gentlest and most soothing efforts 
this reaction, this contraction and rigidity of the abdomi- 
nal muscles, at once sets in, it is best to abandon massage, 
to give up all idea of its application in such a child. 1 

6. Massage must not be applied more than twice per 
day. In my own experience I have found that all the 
good effects can be obtained by one application per day. 

My practice is to make or have made one application daily 
for two to three weeks, and then every other day, and lastly, 
twice a week for the rest of the requisite period. 

7. Each seance (session) must not last more than ten 
minutes ; usually six minutes suffice. In mild cases a sit- 
ting of four minutes will be amply long enough. 

8. Each seance must begin with a careful, gentle strok- 
ing of the skin with the well-warmed hand. This proced- 
ure is absolutely necessary as a sort of preparation for the 
more forcible movements which are not so readily toler- 
ated by the little ones ; in fact, it Would be impossible to 
make them if we were to begin with them. 

In the course of one-half to two minutes the infant is 
accustomed to the gently stroking hand of the masseur ; 

1 Karnitzky, loc. cit. 



MASSAGE 467 

it does not resist any further ; the abdominal walls remain 
relaxed, and we can proceed to the massage proper. 

9. The skin of young infants is very tender and easily 
irritated ; various eruptions, as a result thereof, may be 
called forth or even a serious infection (to which children 
are very susceptible) produced. To avoid such unpleasant 
consequences the masseur shall, before beginning treat- 
ment, cleanse his hands thoroughly with hot water and 
soap, the nails being well brushed, and then dip them 
into a solution of boracic acid (or mild bichloride) as hot 
as can be comfortably borne. They are then thoroughly 
dried with a well-warmed towel. 

10. Karnitzky opposes the, anointment of the operating 
fingers, believing that the manoeuvres cannot be executed 
as well. Though agreeing with him fully as regards 
adults, and even older infants, I rather believe it advan- 
tageous in very young infants as furthering the ease with 
which the movements are made, lessening the tendency to 
reflex contraction of the abdominal walls, and as a safe- 
guard against any undue irritation from friction. As far 
as I have been able to observe, it does not detract from the 
effectiveness of the manoeuvres. 

I therefore advise that for very young infants the fin- 
gers of the operating hand shall be anointed with vaseline 
kept especially for this purpose, and used for no other. 

The parts of the abdomen to be acted upon. 

In the new-born and very young infants the left side 
and the lower border of the abdomen from the left to the 
middle line of the symphysis pubis are the regions mainly 
to be treated. 



468 CONSTIPATION IN INFANTS AND CHILDREN 

Of the right side, that part lying between the costal 
arch and the crest of the ileum need not be treated at all ; 
the region extending from the middle line of the sym- 
physis pubis to a little distance beyond to the right must 
be acted upon. 

The transverse colon it is rather difficult to affect be- 
cause it is so small, and because of the immediate neigh- 
borhood of the large liver which frequently covers much 
of it. In this region much pressure cannot be made with- 
out immediately exciting vomiting. 

In infants three or four months old, the left side and 
the lower boundary of the abdomen to the left are still 
the principal parts, but the right side has already acquired 
some importance because the esecum and ascending colon 
have already considerably developed, especially in hand- 
fed children. 

In infants from six months on the whole tract of the 
large bowel must be covered in the manipulation as in 
the adult ; it is now the main part to be massaged. 

In very young infants avoid the umbilicus (so as not to 
cause any loosening or separation of the parts beneath, 
and thus produce an umbilical hernia), and do not make 
any pressure upon the bladder (which, almost always, is 
more or less full). 1 

1 Karnitzkv, loc. cit. 



CHAPTER XII 

TECHNIC OF MASSACxE FOR INFANTS AND YOUNG 
CHILDREN 

In the execution of the various manipulations made 
with a friction movement, the operating fingers must be 
held closely to the skin of the infant's belly, so that the 
fingers and the skin shall move as one and act as one 
upon the parts beneath. This is of much advantage for 
the effectiveness of the manoeuvre, and readily guards 
against any irritation or undue excitation of the infantile 
cuticle. 1 

In view of the very considerable length of the mesen- 
tery in children, and its great mobility, the deeply im- 
pressed skin should not be moved too far out (in the 
circles described) from the point of outset of the manoeu- 
vre 2 (so that there may not be any accidental dislocation 
of bowel). 

A most important rule in the massage of infants is this : 
Never make the pressure so profound or so strong as to 
cause even the slightest pain. An error thus once made 
may frustrate all further efforts at treatment on our part, 
which may succeed at the hands of another and more 
careful person. 

1 Karnitzky, loc. cit. a Ibid. 

409 



470 CONSTIPATION IN INFANTS AND CHILDREN 

Manipulations 

Introductory Effleurage. — The operator sits (or stands, 
whichever is most convenient) to the child's right, with 
his face to the left. The hand, prepared as already 
described, is laid upon the child's belly, so that the con- 
vexity thereof shall lie in the palm of the hand, gently 
and slowly, so that the infant or child may not be fright- 
ened and strong reflex contractions of the abdominal 
parietes be called forth. It is allowed to rest there for 
a few seconds, then a gentle effleurage, a light stroking 
movement with the whole palmar surface, a petting 
movement, is made from above downward ; when the 
symphysis pubis, or nearly there, has been reached, the 
hand is slightly raised, carried back to the point of begin- 
ning, and the movement is repeated. 

This manipulation, which is a sort of preparation for 
the child, need not take more time than a minute or two. 

It should always precede the massage proper both in 
infants and children. 

Manipulation I. — The operator, in the position de- 
scribed above, places his hands so that the lingers shall 
reach just beyond the umbilicus (about one centimetre) 
over on the left side. The index, middle, and ring fingers 
(if the hand is large, the first two alone will suffice) are 
flexed somewhat in the second joint, and the pulpy por- 
tion of the tip set in firm contact with the skin of the 
belly. The remaining finger or fingers are held extended, 
and abducted from the others, or they can be closed into 
the palm of the hand. 

Beginning at a point about one to one and one-half 
centimetres from the umbilicus (to the left), light frictions 



MASSAGE FOR INFANTS AND YOUNG CHILDREN 471 



are made, the force of the pressure being gradually in- 
creased. Moving from one point as a centre larger and 
more eccentric circles are described by 
the operating fingers, the force of the 
pressure increasing with the enlarge- 
ment of the circle. Then the radius 
of the circle, and with it the force of 
the pressure, is diminished, and the fin- 
gers return to the point of beginning. 

This manoeuvre is carried out in 
various directions, the hand and fingers 
being moved down to the necessary points until the whole 
left side, from the edge of the tenth rib down to the immedi- 
ate vicinity of the symphysis pubis, has been gone over. 1 

Time required, two to three minutes. 





Manipulation II. — The operator is in the position 
already described. The hand is laid upon the belly, upon 



1 Karnitzky, loc. cit. 




472 CONSTIPATION IN INFANTS AND CHILDREN 

the left side, either obliquely from right to left, so that the 
tips of the ringers shall be close to the spleen, or straight 
in a vertical line, fingers pointing 
upward to the face. The first fingers 
are flexed in the second joint, and 
the tips rest upon the child's belly. 
A friction and kneading (petrissage) 
movement in very small circles 1 is 
made. The lines of the manoeuvre 
run from above downward in a ver- 
tical line. The small intestines and 
the large bowel (whatever of it is on the left side, but 
mainly the sigmoid flexure) are acted upon. 2 
Time required, about two minutes. 
Manipulation III. — For the loiver part of the descending 
colon and for the sigmoid flexure. (When practised on 
young infants, it should always be made with anointed 
fingers.) 

The operator is to the right of the child, facing it. He 
lays his right hand upon the left side of the child's belly, 
on the lower half thereof, so that the finger-points, ex- 
tending a little beyond the crest of the ilium upward, lie 
over that part of the descending colon where it is about 
to pass into the sigmoid flexure. It is placed in such a 
way that the ends of the first three fingers only are in 
close contact with the belly, whilst the rest of the hand 
rises obliquely therefrom. 

Now a stroking (efneurage) movement is made down- 
ward. Then along the crest of the ilium to the symphysis 
pubis ; here, passing over to the right side, the bladder 

1 See Part I., chapter "Massage," page 208. 2 Karnitzky, loc. cit. 



MASSAGE FOR INFANTS AND YOUNG CHILDREN 473 

being avoided, the movement is continued for a short 
distance in this direction. 

Whilst the movement is essentially one of effleurage, it 
is nevertheless intended that a certain amount of deep 
pressure, a sort of kneading or rolling (petrissage) move- 
ment, shall at the same time be made ; all in such a way 
that the collected and hardened fasces will be broken up 
and carried down to the rectum. 




Karnitzky for the same purposes makes the following manipu- 
lations : The thumb of the right hand is placed in the right lumbar 
region on a line with the upper border of the pelvis, and the 
two middle ringers of the same hand are similarly placed on 
the left side. After fixation of the skin, as in all preceding 
manipulations, small circular friction and light kneading move- 
ments are made on the left side, in the course of which the 
force of the pressure is gradually raised, the operating lingers 
being pressed in more profoundly. Moving the finger-tips 
from point to point, the masseur brings them from upward and 



474 CONSTIPATION IN INFANTS AND CHILDREN 

outward, downward and inward, into the hollow of the lesser 
pelvis, all irritation of the bladder being thus avoided. 

Manipulation IV. — (In the execution of this the opera- 
tor can be to either side or at the feet of the child.) 

The right hand is placed upon the right side of the 
child's belly, on the lower part thereof, in such a manner 
that the points of the first three fingers, flexed at the 
second joint, shall rest upon the beginning of the caecum 
in the right inguinal region. A combined friction and 
petrissage movement is made ; the circles, at first small, 
are gradually enlarged until they cover the whole width 
of the caecum and beyond, and then are again diminished ; 
without interruption of the circular movement, the fin- 
gers are carried upward, somewhat outward, and again 
inward, until the whole caecum and ascending colon to 
the costal arch have been manipulated. 

Or it can he made in this ivise. — The operator on the 
left of the child, facing to its right. He lays his hand 
upon the child's belly, palm clown, so that its ulnar bor- 
der shall touch or slightly cover the right half of the 
costal arch, whilst the two middle fingers, flexed in their 
last joint, turn outward toward the upper border of the 
pelvis, the crest of the ilium, of the same side. Circular 
frictions are made along the line of the large bowel, 
downward and outward, upward and downward. 1 

Manipulation V. — The operator at the feet of the child, 
facing it. The tips of the operating fingers are placed 
over the transverse colon on the right side, and the move- 
ment described in Manipulation IV. made over the whole 
length of the transverse colon. 

1 Karnitzky, loc. cit. 



MASSAGE FOR INFANTS AND YOUNG CHILDREN 475 

Manipulation VI. — The operator to the right of the 
child with his face to its feet. The left hand, palm 
downward, is laid upon the belly in the right lumbar 
and inguinal regions, so that the tips of the finger, look- 
ing downward, shall reach almost to the symphysis pubis. 
The hand is laid so that only the ends of the fingers are 
in immediate contact with the belly, whilst the rest of 
the hand is raised obliquely therefrom. 

The movement, an effleurage, with something of a 
petrissage, is now made from below, upward along the 
course of the caecum and the colon ascendens. 

Manipulation VII. : Continuation of VI. — The operator 
now turns around and faces the child. The operating 
fingers are placed, in the manner already described, over 
the beginning of the transverse colon on the right side, 
and with the same effleurage movement are carried over 
to the left side, to the spleen. 

Manipulation VIII. : Continuation of VII. — Same as 
Manipulation III., with this difference, that the point of 
outset for Manipulation VII. is from beneath the lower 
border of the twelfth rib, over about the point of begin- 
ning of the descending colon. 1 

Manipulation IX. — The operator stands to the left of 
the child. The thumb of the right hand is placed upon 
the right side of the child's belly, on the lower part 
thereof, about the beginning of the cascum, the radial 
surface of the thumb in contact with the skin of the 
belly. 

From here it is carried with a combined effleurao-e and 
petrissage movement over the cascum, colon ascendens. 

1 See Part I., page 226, Manipulation 3, a, b. c. 



476 CONSTIPATION IN INFANTS AND CHILDREN 

transverse colon, descending colon, and sigmoid flexure 
to the beginning of the rectum. 

By this movement faecal accumulations and indurations 



are broken down and carried upward and over and down- 
ward ; the intestinal parietes are stimulated and aroused 
to more energetic action. Thus, all the good effects of 
massage are realized from it. 

Manipulation X. (rather irritating to young infants ; 
especially applicable to very obstinate cases). — The 
operator stands to the right of the child, facing its feet. 
The left hand is placed upon the abdomen in the inguinal 
region in this way that the tips of the fingers (the first 
three ; little finger abducted) shall rest about over the 
beginning of the caecum. Then a short, quick, effleurage 
movement is made that carries the fingers forward, but 
raises them from the skin after they have travelled 
a short distance, after the manner of the carpenter's 
plane. Then the fingers are replaced about the mid- 



MASSAGE FOR INFANTS AND YOUNG CHILDREN 477 

die of the region travelled over, and the movement is 
repeated. 

This movement is continued until the whole caecum 
and ascending colon have been acted upon. Then the 
operator faces around ; the fingers of the right hand are 
placed, in the manner described, upon the left side, so that 
the tips are just at the border of the twelfth rib ; the 
same manipulation as already just described is made from 
above downward until the whole descending colon and 
sigmoid flexure are gone over. 

Karnitzky also makes tapotement in children over a year 
old, beating or clapping the belly. I do not find this at 
all necessary. If the manipulation is practised at all in 
children, it should be made with the hand partially flexed, 
and holding an air-cushion as it were, as described in 
Part I., chapter on " Massage," Group E. 

Punctation is not to be practised on infants and young 
children ; they bear it badly. 

Application. 

In the early part of the infantile life, up to four months, 
massage of the transverse colon should not be made for the 
reason, already set forth elsewhere, of the immediate neighbor- 
hood of the stomach, and because, being covered in great part 
by the very large liver, it cannot be readily reached. 

For the new-born, i.e. infants a few days old. on whom 
it is desired to practise massage for any of the reasons 
mentioned, to the age of six weeks : 

(a) Introductory effleurage. 
(6) Manipulation I. — mainly. 

Manipulation II. (in children under throe 
weeks this can be omitted). 



478 CONSTIPATION IN INFANTS AND CHILDREN 

For infants from six weeks to four months old: 



00 


Introductory effleurage 


0) 


Manipulation I. 


0) 


Manipulation II. 


00 


Manipulation III. 




Close with («). 


For infants from four to ten months : 


In the earlier pe; 


dod, — 


00 


Introductory effleurage 


0) 


Manipulation I. 


0) 


Manipulation IV. 


00 


Manipulation III. 




Close with (#). 


In the later period, — 


00 


Introductory effleurage 


0) 


Manipulation I. 


0) 


Manipulation IV. 


00 


Manipulation VI. 


(0 


Manipulation VII. 


(/) 


Manipulation VIII. 



From ten months to two and one-half years 

(a) Introductory effleurage. 
(6) Manipulation IV. 



(c) Manipulation VI. ! f (5) Manipulation IX. 

(d) Manipulation VII. ' aiternatm g Wltn \ (,) Manipulation X. 

(e) Manipulation VIII. J 

From two and one-half years on: 

(«) Introductory effleurage. 
(5) Manipulation II. 
(<?) Manipulation IV. 
QP) Manipulation V. 

(e) Manipulations VI., VII., VIII., alternate 
with Manipulations IX., X. 
Close with (a). 



MASSAGE FOR INFANTS AND YOUNG CHILDREN 479 

In children over three years old, tapotement, beating of 
the belly (with the hand partly closed, so as to hold an 
air-cushion, as already described), may be made as a 
closing movement. 

Where, for any reason, the massage must be made by the 
mother or nurse, I teach her : 

f (a) Introductory effleurage. 
For young infants \ (&) Manipulation I. 
[ (e) Manipulation II. 

For infants a year f (a) Introductory effleurage. 
old and for young \ (6) Manipulation IX. (of first importance), 
children [ (c) Manipulation X. 

Older Children 

As regards older children, from the age of eight 
years and upward, we will be governed as to the manipu- 
lations to be practised in their treatment by massage, by 
the state of their physical development. In the strong 
and robust the manipulations made in adults will be 
employed, whilst for the iveak and poorly developed the 
movements just described for younger children will be 
selected. 



CHAPTER XIII 

SPASTIC CONSTIPATION 

The nature and character of spasmodic constipation 
have already been fully set forth in a previous chapter. 
Fleiner, who more particularly called attention to this 
form of constipation, reports also the cases of children 
thus affected. 

It is the same in children as in adults, and manifests 
itself by the same symptoms. 

The treatment has already been given in detail. 

It need hardly be said here that if belladonna is prescribed, 
it must be directed in doses appropriate to the age of the child. 
As to what the dose should be, writers vary considerably. 
Whilst some obtain very satisfactory results with small doses, 
others have found that, most frequently, only full doses produce 
the desired effect. Ringer 1 has prescribed as much as ten and 
even twenty minims of the tincture (English) three times daily 
for children with incontinentia urinse, and Phillips has done 
likewise. 2 I myself believe, from careful observations, that 
not infrequently very good results are obtained with very small 
doses regularly administered at sufficiently frequent intervals. 
As a rule the dose will be : 

Of the Extract, from grain ^L to ^, three to four times dailyc 
Of the Tincture, from "i iv to x, three times daily. 

1 S. Ringer, Handbook of Therapeutics. 

2 Materia Medica and Therapeutics. 

480 



SPASTIC CONSTIPATION 481 

The extract can be prescribed in a fluid mixture ; thus 

I£ Extract. Belladonna. gr. J-l 

Syrup. Rub. Id. aut Syr. Rhei Aromat. § i 

Aq. Destill. § ii 

M. Sig. 1 teaspoonful 3 to 4 times daily. 

Fleiner has obtained the best results with the oil 
clyster. 

Treatment of Fissure of the Anus 

To treat the fissure of the anus is to treat the constipa- 
tion dependent upon it. 

The treatment will depend upon the question whether 
the pathological condition .that confronts us is really an 
"irritable ulcer" of the anus, or whether it is a mere 
fissure or crack that does not involve the sphincter. 

The irritable ulcer is the form generally seen in children. 

The most appropriate treatment is " forcible dilatation." 
This is readily applied, and gives immediate relief. The 
procedure is very brief for young children, and does not 
require the administration of an anaesthetic. 

It is done in this wise : 

The child is laid on its back upon a high couch or 
table, or it is placed upon the knees of the mother or 
nurse on its belly, with its thighs hanging down. The 
physician introduces, carefully, into the anus the index- 
finger or thumb of one hand, then of the other hand, 
the fingers being back to back, as already described, and 
stretches the sphincter fully and quickly; a grating, 
crunching noise is sometimes heard l when this has been 
accomplished. 

1 Jacobi, Intestinal Diseases of Infancy and Childhood. 



482 CONSTIPATION IN INFANTS AND CHILDREN 

Fissures or cracks are most usually seen in young 
infants, 1 and are generally associated with redness and 
excoriation of the integument immediately surrounding 
the anus. They are readily visible when the nates are 
fairly separated. These fissures or cracks occasionally 
get well without any treatment ; generally we can bring 
about a cure without any resort to forcible measures, 
simply by local applications. According to Wharton, 2 
even true irritable ulcer in the young infant can be suc- 
cessfully so treated. 

To fissures or cracks a solution of silver nitrate, twenty 
grains to the ounce (of water), is applied with a brush, or 
with the applicator and cotton-wool, until a white film 
forms on the surface. Van Bur en has always succeeded 
with a solution ten grains to the ounce (of water). 

The irritable ulcer of the young infant will be touched 
with the solid stick. 

The parts are then dusted with aristol or dermatol. 
Some recommend the application of an ointment of iodo- 
form, but the odor of this is suggestive of so many 
things and so abhorrent to most people that I do not 
advise it, especially as we can accomplish all the desired 
good with the benzoated ointment of the oxide of zinc. 3 

Furthermore, to hasten the healing we must see to it 
that the faecal discharges are soft. To accomplish this, we 
may resort to various medicines administered internally 
(see " Formulary "■)., or to rectal injections. Van Buren 
advises, as the best measure known to him, an enema of 



1 Van Buren, loc. cit. 

2 American System of Diseases of Children, edited by Starr. 

3 Van Buren, loc. cit. 



SPASTIC CONSTIPATION 483 

warm, even hot, water just preceding each stool, with 
the addition of melted vaseline or sweet oil just before 
the tube is withdrawn. 1 I direct the daily injection 
into the rectum of 3 ii-S ss of the best olive oil. For 
this purpose I find that a hard rubber syringe, of an 
ounce or two capacity, is the best. 

In addition, the various dietary articles that tend to 
loosen the bowels, as stewed prunes, prune juice, prune 
paste, molasses, syrup, etc., are ordered for the child. 

After defecation the parts must be carefully cleansed ; 
absorbent cotton (not sponge, or diaper, or other cloth) 
and a mild solution of boracic acid are to be used. 

A careful compliance with these directions will be fol- 
lowed by a rapid cure. 

1 Van Buren, loc. cit. 



CHAPTER XIV 

FORMULARY 

Laxatives for the Youngest Infants 

1 Manna, crystalliz. 10.00 (=3 viii) 

Aq. fervid. 100.00 (= Siii 3iiss) 

M. Sig. In tablespoonful doses. 



I£ 2 Manna. Optim. 3 ii 
Aq. Anethi 3i 

M. Sig. Teaspoonful (3i) doses. 



I£ 3 Manna. Optim. 3 ii 
Syr. Rosar. % i 

M. Sig. Teaspoonful (3i) doses. 



3 Syr. Manna. 3vi 

Syr. Rhei Aromat. 3 iii 

M. Sig. In doses of 3 ss-i. 

For somewhat older infants (after second or third month) 

I£ 4 Magnesia. Carbon. 3 i 

Manna. Optim. 3 ii 

Tinct. Rhei Co. 5 3i 

S} r r. Rosar. ad 5 iss 
M. Sig. In doses of 3 i-ii. 

1 Gerhard, Handbuch der Kinderkr., loc cit. 

2 Ellis, Diseases of Children. 

8 Ibid. 4 Ellis, loc. cit. 6 Tinct. Rhei can be used instead. 

484 



FORMULARY 485 

ty Magnesia. Usta. 3 i-ii 

Syr. Rhei Aromat. ss 

Syr. Rosar. § ss 

M. Sig. In teaspoonful (3 i) doses. 

For infants (from six months on) and young children : 
Pulvis Puerorum Hensleri, 1 Pulvis Rhei Co. 
$ Sapo. Medicata. 
Magnes. Carbon. 
Rhei rad. pulv. 

Sacchar. Alb. aa 60 parts 

Ole. Foenicul. Mth.. 1 part 

M. triturat. bene et ft. pulv. 
Sig. Dose, live to fifteen grains. 



1} Pulvis puerorum Hufelandi, Pulvis pro Infantum Hufe- 

landi. 2 



B 


Magnesia. Carbon. 


15 parts 




Rad. Glycerrhiza. 


20 parts 




Rad. Rhei pulv. 


10 parts 




Valerian. Rad. 


5 parts 




Croci 


1 part 




Semin. Anis. 


15 parts 


M. triturat. 


bene et ft. pulv. 




Sig. Dose, 


five to fifteen grains. 





I£ Podophyllin grs. -viii 3 

Iridin. grs. v 

Spirit. Amnion. Aromat. Si 
Digest for several days and then filter. 

Sig. Dose, one or two drops on a piece of sugar or mixed 
with any syrup. For a child a year old. 

1 Strumpf, Allgemeine Pharmakopoe. 

2 Strumpf, loc. cit. 

3 Neiv York Medical Record, May 7, 1887. 



486 CONSTIPATION IN INFANTS AND CHILDREN 

I£ Podophyllin gr. i 

Spirit. Vin. Rectif. 3 iss 
Syrup. Altha. ad § iv 

M. Sig. A half-teaspoonful daily. 1 

For Children 

$ Fruct. Tamarindi 
Sig. 3 ii at a dose. 



5 Mannse 3 vi 2 

Magnes. Carbon. 
Sulph. loti aa § iss 

Mellis f 3 vi 

M. Sig. Dose, one-half to two teaspoonfuls according to age. 



I£ Infus. Laxativ. Viennens. 

Syr. Rhei Aromat. aa § i 

M. Sig. One teaspoonful every three hours. For a child 
two and one-half years old. Pleasant and effective. 



M. Sig. 


$ Soda. Phosphat. 

Syr. Limon. 

Decoct. Hordei 
Dose, two tablespoonfuls. 


Si 3 
3 ss 
Svi 
A pleasant aperient. 


$ Magnesia. Sulphat. 3 ii 4 
Acid. Sulphur, dilut. gtt. v 
Syr. Aurantii 3 iii 
Aq. Carui 3 v 
M. Sig. 3 ii every hour till bowels act. A more active purge 
For a child three years old. 



1 Bouchut, E., also in Wilson, Complete Medical Pocket Formulary. 

2 Ferraud, Wilson, Complete Medical Pocket Formulary. 

3 Ellis, loc. cit. 

4 West, Diseases of Children. 



FORMULARY 




Emuhion of castor oil (Trousseau) l 




5 Ole. Ricini 


Si 


Vitel Ovi 


semissem (|) 


Tere simul et adde 




Aq. Flor. Aurant. 




Syr. Simpl. 


aa § i 


Aq. Destill. aut Fcenicul. 


S vi 2 


M. ft. Emulsio. s. a. Sig. § i at a 


dose. 



487 



Alterative Aperient : 

I£ Mass. pillul. Hydrarg. grs. i-ii 
Syr. Rhei Aromat. § i 

M. Sig. 3 i every two to three hours till bowels move (or 
till stool is changed in appearance). 

Oatmeal Water 

First prepare an oatmeal porridge ; take a heaping teaspoon- 
ful of this, put into a quart of cool water, heat with constant 
stirring to the boiling-point, and strain. 3 



Take a large tablespoonful of fine oatmeal, put into a sauce- 
pan with a quart of water, allow it to boil down to three-fourths 
of a quart. Strain. 

Soap Suppository- 
Must vary in strength according to the age. For a child of 

two months, one grain of soap with ten grains of Oleum Theobrom. 

will be sufficiently strong ; at one year, five grains of soap can 

be put into the suppository. 

Or in place of the suppository we may use the soap stick ; 

commonly, the ordinary brown soap is used for this purpose. 

Starr directs that Castile soap be employed. It is prepared 

1 Clinical Lectures. 

2 For other formula for emulsions, see " National Formulary." 

3 Starr, Hygiene of the Nursery. 



488 CONSTIPATION IN INFANTS AND CHILDREN 

thus : Cut from a bar of good Castile soap a piece two inches 
long and half an inch thick. Scrape this into a cone, pointing 
one end like a sharpened pencil, but with a blunter point and 
more gradual slope ; make it quite smooth by rubbing the sur- 
face with a wet rag. When the soap stick is to be used, anoint 
the pointed end with vaseline, and gently insert into the rectum 
until the sphincter closes over it. 1 

1 Starr, loc. cit. 



INDEX 



Accumulation, enormous, of faeces, 

Case 25, 148. 
Adulterated, articles of food, 102. 
Adulterations, 200. 
Age, old, 101. 
Ammonium chloride, 304. 
Anal fissure, 135, 419. 
Anus, excoriation of, 419. 

fissure of, 343. 

malformation of, 387. 
Appendicitis, causation of, 136. 
Appendix vermiformis, 10. 

orifice of, 10. 
Arch, transverse, 11. 
Arteris : 

arteria sigmoidea, 19. 

colica dextra, 19. 

colica media, 19. 

colica sinistra, 19. 

external hemorrhoidal, 20, 

hsemorrhoidal superior, 20. 

ileo-colic, 19. 

inferior mesenteric, 19. 

inferior pancreatico-duodenal, 19. 

middle hsemorrhoidal, 20. 

pancreatico-duodenalis, 18. 

superior mesenteric, 18. 

vasa intestini tenuis, 19. 
Atony, of the intestines, 94. 

causes of, 95. 

of the intestine, in chlorosis, 104. 

of the intestine, as a sequel of in- 
fectious diseases, 104. 

of the intestine, symptomatology, 
105. 

of the intestine, symptoms, gen- 
eral, 100. 



of the intestine, symptoms, local, 

109. 
of the pouch of the rectum, treat- 
ment of, 311. 
of the stomach, 173. 
with enterospasm, 90. 
Atrophy, essential primary, of the 

large bowel, 79. 
Atzperger's apparatus, 337. 
Auto-intoxication, 173. 

B 

Bandages, belts, for relaxed abdominal 
walls, 201. 
hemorrhoidal, 349. 

Basedowii Morbus, 179. 

Bath, cold-tub, 270. 

Bauchpresse, 37. 

Bauhini valvula, 9. 

Bauhinian valve (can be passed by 
fluids injected into the rectum), 
55. 

Bergeon (rectal injection of sulphu- 
retted hydrogen), 107. 

Bicycle riding, 197. 

Boracic acid, application of, in consti- 
pation, 360. 

Borborygmi, 183. 

Bougies, rectal, for dilatation, 361. 

Bowels, atony of, 94. 
large, 7. 

large, division of, 9. 
in young infants, 461. 



Cecum, 9. 

Carbonic acid, for painful conditions 
of rectum, 339. 



489 



490 



INDEX 



Catarrh, chronic, of the intestine, treat- 
ment of chronic constipation 
caused by, 317. 
Charcot-Leyden crystals, 128. 
Chlorosis, 104-183. 
Cincture-feeling in enterospasm, 90. 
Clysters, 264. 
Colics, treatment of, without narcotics 

or liquor, 447. 
Colon, ascending, 10. 

congenital obstruction of, 395. 
descending, 12. 
malplacement of, 397. 
transverse, 11. 
Compress, cold, abdominal (Neptune's 

girdle), 275. 
Complications, 306. 
Concretions, 139. 

Case 20. Intestinal concretion, 

144. 
Case 22. Concretion of chaff of 

oats, 146. 
Case 23. Concretion of iron and 

magnesia, 147. 
Case 24. Concretion of sawdust, 
148. 
Confectio sennse, 372. 
Constipation, classification of, 42. 
definition of, 42. 
etiological factors, 42. 
acute, causes of, 46. 
acute, causes of, in children, 412. 
acute, definition of, 43. 
acute, treatment of, 416. 
atonic, 94. 

atonic, causes of, 95. 
atonic, diagnosis of, 112. 
atonic, diagnosis of, in children, 

437. 
chronic, causes of, 57. 
chronic, causes of, in children, 418. 
chronic, definition of, 43. 
chronic, from impaired physio- 
logical functioning, 86. 
congenital, 62, 387. 
congenital, treatment of, 416. 
habitual, 86. 



habitual, in infants, causes of, 
423. 

habitual, in older children, causes 
of, 434. 

hysterical, case of, 52. 

in old people, treatment of, 365. 

of the insane, 93. 

of the insane, treatment of, 93. 

spastic, 87. 

spastic, treatment of, 324. 

spastic, treatment of, in children, 
480. 
Contra-indications to massage, 260. 
Corde colique transverse, 84. 
Cough, irritating, 180. 
Cow's milk, feeding with, 425-442. 
Crises enteriques, 88. 
Cushion, Feilchenfeld's, 241. 

D 

Debility from protracted maladies, 
cause of chronic constipation, 
treatment of, 322. 
Defecation, 35. 

Diagnosis of atonic constipation, 112. 
of atonic constipation, in chil- 
dren, 437. 
Diaphragms, 78. 
cases of, 78, 79. 
in the small intestines, 406. 
cases of, 406, 407. 
Case 57, diaphragm at one 
point and a stricture at 
another, 407. 
treatment of, 409. 

Case 58, illustrating treatment 
of, 409. 
Diarrhoea with constipation, 166. 
Case 35, 167. 
with obstruction, 169. 
case of, 169. 
Diet, dietary regulations, 187. 
Dietetic exercise, 193. 
preparations, 378. 
Dilatation, of the large bowel, 150. 
of the large bowel, in children, 
429. 



INDEX 



491 



forcible, of the sphincter of the 

anus, 331. 
gradual, of the sphincter of the 

anus, 360. 
gradual, of the sphincter of the 
anus, instruments therefor, 361. 
Dislocation, of the bowel, 80. 
of the sigmoid flexure, 84. 
Diverticula, 72, 160. 

false, of large bowel, 163. 
of the small intestines, 164. 

Case of diverticulum of ileum, 
165. 
Diverticulum, congenital, of sigmoid 

flexure, 72. 
Douche (shower bath), 277. 
Drink, 192. 

Drugging of infants, 424. 
Duodenum, 3. 
Duodenum, division of, 4. 
Duration of treatment (massage) , 239. 

E 

Effleurage, 206. 

introductory, 237. 
Electricity, 283. 

faradic current, 285. 

franklinization, 294. 

franklinization, in hysteria, 297. 

galvanic current, 291. 

galvano-faradization, 293. 

general faradization, 294. 

scheme of electrical treatment, 
297. 

selection of current, special indi- 
cations, 297. 

effect upon intestinal secretion, 
297. 

in young children, 457. 
Electrodes, rectal, 289. 
Electuarium lenitivum ( Wintheri), 372. 

Mannse, 372. 
Enemata, 264. 

for infants, fluids for, 451. 

for infants, instruments for, 449. 

how to administer in infants, 450. 
Enteritis Membranacea, 138. 



Enteroliths, 139. 

Case 21, removal of, 145. 
Enteroptosis, 80, 
Enterospasm, 87. 

treatment of, 324. 
Enterospasm and atony, 90. 
Ergot, 302. 
Exercise, 193. 

lack of, 99. 



Faecal vomiting, 29. 
Faeces, appearance of, 39. 

color of, 40. 

composition of, 39. 

constituent elements of, 40. 

microscopical appearance of, 41. 

microscopical exam, of, 41, 127. 

reaction, 40. 
Fats, deficiency in, 98. 
Feeding, artificial, regulations for, 445. 

breast-feeding, rules for, 444. 

improper, 425-443. 
Feilchenf eld's cushion, 241. 
Fissure, anal, in infants, 419. 
Fissure of the anus, 135. 

treatment of, 343-481. 
Flatulence, 109. 
Flatus, 27. 

accumulation of, 29. 

action of, 29. 

mode of discharge, 29. 

recognition of, 29. 
Flexura coli dextra seu hepatica, 11. 
Flexura coli sinistra seu linealis, 11. 
Flexure, left colic, 11. 

right colic, 11. 

sigmoid, 12. 
Foods, deficient in fats, 98. 

deficient in residual matters, 97. 
Force pump, 267. 
Foreign bodies, classification of, 46. 

sharp, swallowed, 47. 

sharp, swallowed, treatment for. 
47, 48. 

Case 1, swallowing of open pen- 
knife, 47. 



492 



INDEX 



Case 2, swallowing of a plate with 

teeth, 48. 
Case 3, glass syringe broken off in 

rectum, 49. 
Case 4, piece of wood driven into 

rectum, 50. 
Case 6, swallowing of hair, 60. 
Formulary, 369. 

for infants and young children, 484. 
Franklinization, 294. 
in hysteria, 297. 
Frequency of treatment (massage), 239. 
Frictions, 207. 

G 

Gall-stone, as a cause of acute consti- 
pation, 416. 

Gases, development of various, 28. 
groups of, that constitute the flatus, 

27. 
volume of, 28. 

Genital organs, diseases of the, 182. 

Genito-urinary diseases, constipation 
from, treatment of, 340. 

Girdle, Neptune's, 215. 

Gravel, river (Flusskiesel), in treat- 
ment of constipation, 363. 

Groin, pain in, 182. 

Gymnasium, pocket, Goodyear's, 261. 

H 

Habitual constipation, 86, 422. 
Haematine, 127. 
Hsematoidin, 127. 
H?emicrania ; 177. 
Hemorrhoidal bandage, 349. 

tumors, injection of, formula for, 
377. 

veins, 133. 
Hsemorrhoids, mode of production of, 
132. 

non-surgical treatment of, 345. 
Halbbad, 270. 
Heart, palpitation of, 176. 
Horseback riding, 197. 
Hydrogen sulphide, in stomach, 27. 
Hydrotherapy, 264. 



Ileum, 6. 

Ileus, mechanical, 170. 

mechanical, treatment of, 308. 
paralyticus, 170. 
Infants, drugging of, 424. 
Inflation, of large bowel, 123. 
Injection, formula for, of haemorrhoidal 

tumors, 377. 
Injections, hot, 55. 
large, 55. 
of oil, 353. 
rectal, 270. 

rectal, in jaundice, 270. 
Injury, traumatic, of small intestines, 
causing acute constipation, 413. 
traumatic, of small intestines, caus- 
ing acute constipation, case of, 
413. 
Insomnia, 181. 

Intestinal concretion, voluminous, case 
of, 61. 
paralysis, treatment of, 310. 
Intestines, disconnection of the whole 
digestive tract, case, 404. 
division of, 3. 
large, malformations of, 62. 

case of abnormally developed 

colon, 63. 
case of enormous development 

of colon, 65. 
case of enormous development 

of sigmoid flexure, 70. 
case of undue size of sigmoid 
flexure, 69. 
small, 3. 

small, length of, 3. 
small, malformation of, 398. 
Intestinum crassum seu amplum, 7. 
Introductory effleurage, 237. 
Itching at the anus, 110. 



J 



Jaundice, 171. 

Case 37, 171. 

Case 38, 172. 
Jejunum, 6. 



INDEX 



493 



K 

Kahn's roller, 241. 
Kammgriff, 217. 

Kinesipathy (Swedish movement cure) , 
243. 



Levator am* muscle, action of, 38. 
Linea interspinalis, 119. 
Linea spino-umbilicalis, 119. 
Liver, in infants, 460. 
torpid, 170. 

M 

Machine gymnastics, 259. 
movement cure, 259. 
Malformations, of the anus and rectum, 
387. 
of the anus and rectum, synoptic 

table of, 392. 
of the colon, 393. 
of the small intestines, 398. 

Case 46, congenital obliteration 

of, 398. 
Case 47, congenital obliteration 

of, 399. 
Case 48, imperforate ileum, 

401. 
Case 49, imperforate ileum, 

402. 
Case 50, no connection be- 
tween the small intestines 
and the large bowel, 403. 
Case 51, no connection be- 
tween the small intestines 
and the large bowel, 403. 
Malplacement of the colon, 397. 
Manipulations, 214. 
schedule of, 238. 
for infants, schedule of, 477. 
Massage, 203. 

technic of, 206. 
abdominal, 211. 
abdominal, rules for, 211. 
abdominal, operative technic of, 

213. 
contraindications to, 260. 



in infants, 452. 

in infants, rules for, 464. 

in infants, technic of, 469. 

in infants and children, manipu- 
lations of, 470. 

instrumental, 240. 
Medicines, 299. 
Mental work, mental worry, cause of 

constipation, 101. 
Mesocolon, transverse, 11. 
Mesorectum, 13. 
Morbus Basedowii, 179. 
Movements, active, 245. 

against resistance, 249. 

passive, 256. 
Mucus in stool, 127. 

N 

Neglect of the call of nature, 95. 
Neptune's girdle, 275. 
Nerves, of the intestinal tract, 21. 
the inferior hemorrhoidal, 24. 
the superficial perineal, posterior 

branch of, 24. 
the cutaneous (from fourth sacral) , 
24. 
Nervous system, functional disturb- 
ances of, 176. 
Neuralgia, lumbo-abdominal, 180. 

trigeminal, 177. 
Neurasthenia, constipation caused by, 

treatment of, 319. 
Noises in the abdomen, 183. 
Nux vomica, strychnine, 299. 

O 

Oatmeal water, 487. 
Obesity, 101. 
(Edema, 159. 
Oil, how warmed, 354. 

injections of, 353. 

injections, technic of, 354. 

injections, tip for syringe for, 
355. 
Ointment, for hemorrhoids, 375, 

for rectal pain, 375. 



494 



INDEX 



Old people, constipation of, treatment, 

369. 
Otalgia, from constipation, 180. 
Overalgia, 181. 



Pain in enterospasm, 89. 
Palpation of large bowel, 116. 
Paralysis, of intestine, treament of, 

310. 
Particles, coarse, action of, 33. 
Percussion of large bowel, 117. 
Peristaltic movements, visible upon 

the abdominal walls, 126. 
Peristalsis, intestinal, 30. 

influence of carbonic acid on, 34. 

influence of oxygenation on, 34. 

influence of venous stasis on, 34. 

of the large bowel, 32. 

of the small intestines, 31. 
Peritonitis, tubercular, 420. 

case of, 420. 
Petrissage, 208. 

Physostigma, physostigmatis faba, 301. 
Plaetschern (splashing), in bowel, 130. 
Plexus, aortic, 22. 

hypogastric, 22. 

inferior mesenteric, 22. 

myentericus of Auerbach, 21. 

of Meissner, 21. 

solar, 21. 

solar, vibration of, 232. 

superior mesenteric, 22. 
Plica sigmoidea, 16. 

transversalis recti, 16. 
Proctitis, 138. 

Prognosis of habitual constipation, 131. 
Psychoses, 181. 
Psychrophor, 341. 
Pump, force, 267. 
Punctation, 218. 
Pus, 127. 

K 

Reading at stool, 96. 
Rectum, 13. 

and anus, malformations of, 387. 



Case 40, complete closure of the 
rectum, 388. 

case of sloughing of, 138. 

distention of, 155. 

irritable (hysterical), treatment of, 
333. 

spasmodic stricture of, 90. 
Relaxation of abdominal walls, 200. 
Restaurateur of Sachs, 261. 
Riding, bicycle, 197. 

horseback, 197. 

in a vehicle, 197. 
River gravel, in treatment of constipa- 
tion, 363. 
Roller, Kahn's, 241. 
Rowing, 197. 

apparatus of Ewer, 261. 

apparatus of Sachs, 261. 
Rubbing, cold moist, 273. 
Rules, for abdominal massage, 211. 

for exercise, 198. 

for kinesipathy, 245. 

for walking, 196. 

of conduct, 185. 



Sacculated appearance of large bowel, 

15. 
Sacculi Horneri, 18. 
Schedules of manipulations, 238. 

of manipulations, for infants, etc., 
477. 
Sciatica, 181. 

Senator, hydrothionamie, 107. 
Sennse, confectio, 372. 
Shower bath, 277. 
Sigmoid flexure, 12. 

dragging down of, 154. 
Soap, suppository, 487. 

stick, 487. 
Solar plexus, vibration of, 232. 
Sounds, heard on palpation of bowel, 

120. 
Spasm, of intestinal muscles, general, 
partial, 87. 
of the sphincter ani (without local 
lesion), treatment of, 330. 



INDEX 



495 



Spasmodic stricture of the rectum, 90. 

treatment of, 329. 
Spastic constipation, 87. 
Spermatic cord, pain in, 182. 
Sphincter, O'Beirne's, 35. 

spinal centre of, 36. 
Sphincter of the anus, 14. 

external, internal, third, 14. 
irritable, 91. 

spasmodic contraction of, 91. 
Splashing (plaetschern), heard in 
bowels, 130. 
heard in left colic flexure, 121. 
Stomach, atony of, 173. 

in infants, 458. 
Stretching of the sphincter ani, for 

constipation, 359. 
Stricture of the intestine, congenital, 
404. 
Case 53, of duodenum, 404. 
Case 54, of duodenum, 405. 
of the intestine, diagnosis of, 115, 

124. 
of the intestine, interstitial, fre- 
quency of, 116. 
of the intestine, tuberculous, 113. 
Suggestion, treatment by, 364. 
Sulphuretted hydrogen, rectal injec- 
tion of, 107. 
Suppositories for haemorrhoids, 376. 
Swedish movement cure (kinesi- 

pathy), 243. 
Symptomatology of atonic constipa- 
tion, 105. 
of atonic constipation in children, 
437. 

T 

Table of temperatures of water (defi- 
nition of the various expres- 
sions, warm, hot, etc.), 282. 

Tcenioe, of the large bowel, 10. 

Tapotement, 209. 

Teeth, bad, 101. 
want of, 101. 

Temperature of water for clysters, 266, 
451. 

Testicle, pain in, 182. 



Tic douloureux, 177. 

case of, 178. 
Tonsil, lingual, enlargement of, 182. 
Treatment, effects of, 305. 

frequency of (massage), 239. 

of constipation due to atony, 185. 

of constipation due to atony, in 

infants, 440. 
of constipation due to atony, in 

older children, 455. 
of conditions related to atony, 308. 
of constipation dependent upon 

genito-urinary troubles, 340. 
of relaxed abdominal walls, 201. 
Tumors, fsecal, 139. 

Case 16, mistaken for nephritis, 

140. 
Case 17, mistaken for organic 

tumor, 141. 
Case 18, mistaken for malignant 

disease of the liver, 141. 
Case 19, mistaken for wandering 

kidney, 142. 
abdominal, diagnosis of, 123. 
Typhlitis, 136. 

U 
"Ulcer, irritable, 135. 
Ulcers, by distention, 159. 



Valve, ileo-csecal, 9. 

Valves of the rectum, 16. 

Varicocele, 159. 

Veins, 20. 

W 

Walking, 193. 

Wash, for haemorrhoids, 377. 

Water, cold, abstaining from, 99. 

cold, effects on intestinal canal, 99. 

Winternitz, device for applying cold 
to the rectum, 338. 

Worms, as a cause of acute constipa- 
tion, 416. 



Z 

Zander institute, 259. 
Zinc sulphate, 302. 



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